Counseling & Testing Intake Form Child / Adolescent

Please answer these questions as they pertain to the child:

Psychological Assessment (testing)CounselingBoth

He/himShe/herThey/them

Describe the current problems you are having, when the problems began, and if appropriate, what triggered the

Within the past three months, have you experienced any of the following:

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(Continued) Within the past three months, have you experienced any of the following:

Hypervigilance (constantly assessing environment potential for threats)History of Psychiatric HospitalizationsShynessDifficulty interacting sociallyIntrusive disturbing thoughtsSelf-injury (If yes, please list what type below:)

NoYes (mark all that apply below)

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NoYes (mark all that apply below)

Left HandedRight HandedAmbidextrous

WalkingVisionHearing

MarriedDivorcedSeparatedTogether, but Never Married

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Physically AbusedSexually AbusedVerbally/Emotionally AbusedExposure to domestic violence

NoYesWas it helpful? NoWas it helpful? Yes

NoYes, (please include undiagnosed but suspected disorders)

Note: It is recommended that your child receive a wellness exam every 12 months.

	Diagnosis	Date Diagnosed	Physician

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	Diagnosis	Date Diagnosed	Physician

	Diagnosis	Date Diagnosed	Duration	Physician

	Medication	Dosage	Time taken	Prescriber

NoYes, please list below

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AcademicsSocialBehavior

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Assessment of Substance Use (10 and older):

NoYesInpatientOutpatient

Counseling & Testing Intake Form Child / Adolescent

Presenting Problem(s):

Developmental History:

Assessment of Family Domain:

Assessment of Abuse/Trauma:

Assessment of Behavioral Health Domain:

Assessment of Medical Domain:

Assessment of Basic Living Skills Domain:

Assessment of Social/Relationship Support Domain:

Assessment of Education Domain:

Assessment of Vocation Domain:

Assessment of Community/Legal Domain:

Assessment of Housing Domain:

Assessment of Financial Domain:

Assessment of Crisis/Risk Domain:

Assessment of Cultural/Religious Domain: