Tosa Pediatrics Therapies Intake Questionnaire
Child's Name
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First Name
Last Name
Child's Date of Birth
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Month
.
Day
Year
Date
Presenting Concern
What brings your child to counseling at this time Is there something specific, such as a particular event? Be as detailed as possible.
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Are there times/situations when it gets better or worse. If yes, explain.
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What have you tried to do or solve/address this problem? How have you been coping with it?.
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History of Presenting Concern
Please check any of the following your child has experienced in the last 6 months.
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Increased appetite
Decreased appetite
Trouble concentrating
Difficult sleeping
Excessive sleep
Low Motivation
Isolation from others
Fatigue/low energy
Low self-esteem
Depressed mood
Tearful or crying spells
Anxiety
Fear
Hopelessness
Panic
Other
Has your child seen a mental health therapist before?
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Please Select
Yes
No
Unknown
List all medications and supplements your child is presently taking and for what reason. For prescriptions, indicate the prescribing provider including name, practice name, address and phone number.
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Who is your child's primary care physician? Family practitioner or Pediatrician? Please indicate the prescribing provider including name, practice name, address and phone number.
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Please describe your child's current and past physical health, sleep habits and eating habits..
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Does your child drink alcohol?
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Please Select
Yes
No
Unsure
Does your child use recreational drugs?
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Please Select
Yes
No
Unsure
Does your child have suicidal thoughts?
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Please Select
Yes
No
Unsure
Has your child ever attempted suicide?
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Please Select
Yes
No
Unsure
Does your child have thoughts or urges to harm others?
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Please Select
Yes
No
Unsure
Has your child ever been hospitalized for a psychiatric need?
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Please Select
Yes
No
Unsure
What else would you like me to know?
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Family of Origin Information
Describe your child’s current living situation. With whom does your child live - with you, your family, others, adoption, foster care, etc? Please include custody and visitation information if applicable.
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How would you describe the relationship between your child's parents/caregivers?
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Close
Full of Conflict
Domineering
Cold
Hot and cold
Loving
Ideal
Reserved
Hostile
Violent
Distant
Other
How would you describe the method of discipline used by your child's mother/caregiver?
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Strict
Fairly Strict
Fair
Lenient
Inconsistent
Other
How would you describe the method of discipline used by your child's father/caregiver?
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Strict
Fairly Strict
Fair
Lenient
Inconsistent
Other
Is there a history of mental illness in your child's family? Please explain.
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Is/was there any type of abuse (physical, sexual, emotional, etc) in your child's family? If yes, please describe the circumstances.
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Please describe what you see as strengths of your child's current home. (Examples might include strong moral values, support, high standards, close family, discipline, religion, etc.)
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Please describe the major activities and interests of your family.
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School
What school and grade does your child attend? Who is their teacher?
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Does your child receive any special services? (IEP, 504) If yes, please explain.
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How would you describe your child's peer relationships/friendships?
Strengths
What do you think are your child's strengths?
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Please describe the major activities and interests of your child.
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Counseling Goals
What would you like to accomplish during your child's time in therapy?
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How will we know when your goals are being met?
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