Child/Adolescent Intake

Child/Adolescent Intake

Parent/Guardian Form
2611 Washington St., Pella, IA 50219 641 628 9599

1701 48th St, Ste. 120, West Des Moines, IA 50266 515 331 0303
Name

First NameLast Name
Date

MonthDayYear
Date
Gender

MaleFemale
Address

Address

Street Address Line 2

CityState / Province

Zip Code
Phone
Email
example@example.com
Did anyone refer you to Heartland? If yes, who?
Primary Insurance Provider
Primary Insurance ID #
Primary Insurance Group #
Primary Insurance Policy Holder
Primary Insurance Holder's DOB
Primary Insurance Policy Holder's employer
Secondary Insurance Provider
Secondary Insurance ID#
Secondary Insurance Group #
Secondary Insurance Policy Holder
Secondary Insurance Holder's DOB
Secondary Insurance Policy Holder's employer
Primary Care Physician
Primary Care Physician's Phone
PCP Address
Other Physician (i.e. Psychiatrist)
Other Physician's Phone
Other Physician's Address
Emergency Contact
Emergency Contact Relationship
Emergency Contact Phone
Alternate Phone
Form completed by
Relationship to child
Primary reason for scheduling appointment:
What do you hope to gain from coming?
Please check any concerns that you have about your child:

Sad or unhappy most of the timeLoss of interest/not enjoying thingsChange in appetite or weightSleeping too muchNot sleeping enoughFeeling restlessFeeling sluggish or slowDecreased energy or fatigueFeelings of worthlessess/guiltConcentration difficultiesCrying spellsCries easilyFeeling helpless/hopelessExcessive anxiety or worryFeeling on edge or moodyIrritability/angerDifficulty making decisionsMuscle tension/pain/headachesFlashbacksNightmaresEasily startledAvoid going places/being with othersNeed to please or be likedFear of failure/disapproval/rejectionIsolates/withdraws from othersSensitive to criticismObsessive/Intrusive thinking
Compulsive behaviors? Please check all that apply.

CountingCheckingHand washing/cleaningPrayingOther
Does your child...

Bite nails/pull hair/pick skinHave panic/anxiety attacksExperience a racing heartHave excessing sweatingExperience tremblingHave shortness of breathHave feelings of chokingHave chest painExperience nauseaFeel dizzyHave chillsFeel numbness/tinglingFeel detachedFear of going "crazy"/dying
Please check any of the following concerns you have about your child:

Inflated self esteem/grandiosityDecreased need for sleepOverly talkative/pressured speechRacing thoughts/Flighty ideasIncreased risk taking behaviorInattentiveness/distractibleDifficulty staying organizedDifficulty following directionsAvoid tasks requiring mental effortFrequently loses itemsForgetful/needs frequent remindersHyperactive/On the go all the timeFidgetyImpulsiveEasily boredDemands attentionDoesn't finish thingsDaydreams/in own worldPoor non verbal communicationDifficulty initiating social interactionsIs seen as weird/different by peersHas few or no friendsRestricted interestsInflexibility in routines/behaviorRepetitive motor movementsSensory issues (textures/sounds/etc)Restricting eatingFear of gaining weightBody image difficultiesBinge eating/Lack of control eatingCompensating for eating (vomiting, over exercising, laxatives)Suspicious/paranoid of othersHearing/seeing things others don'tPuzzled about what is real/unrealGaps in memoryFeeling thoughts are controlledPerforms below abilityProblems completing homeworkHates going to school/skips schoolDifficulty following school rulesConflict with or talks back to teachersCan't be trusted/frequently liesDefiant/breaks house rulesTalks back to adults/parentsIssues related to sexuality/genderSexual addictions/pornography useScreen/phone/video game addictionsAlcohol, nicotine or drug useLow self esteem/self worthSelf-harm (cutting, burning, etc)Suicidal thoughts/attempts
Are there any other concerns not listed above you want to discuss?
How have these concerns impacted your child's/family's daily life (relationships, activities of daily living)?
What triggered/caused these symptoms and how long ago did they begin?

Past Mental Health Services: Has your child previously received inpatient, IOP/partial, or psych assessment services?

	When?	Where?	Outcome?
1.
2.
3.

Trauma History
Is your child currently living in a safe and stable residence?

YesNo
Has your child been the victim of abuse and neglect?

YesNo
If yes, what type of abuse did he or she suffer?

PhysicalSexualEmotionalOther
Has your child been the perpetrator of abuse/neglect?

YesNo
If yes, what type of abuse did he or she inflict?

PhysicalSexualEmotionalOther
Other traumas?

Car accidentDeath/serious illness of a loved oneVictim of/witnessed a crimeHarassmentOther
If you checked "other traumas" above, please explain.
Family History
Does anyone in your immediate or extended family suffer from a mental health issue (substance use/suicide/depression/etc)? Type yes or no.
If yes, explain who and the nature of the problem.
Does your child have any past or current significant medical concerns/surgical procedures? If yes, please explain
Current Medications (Name of med, dosage, reason for taking)
Has your child ever had a head injury, regardless of loss of consciousness (fell off bike, concussion, car accident)?

YesNo
Does your child have a regular bedtime?
What time does your child go to bed? How many hours of sleep does he or she get nightly?
Substance Use
CURRENT USE. Check any of the following that your child is CURRENTLY using.

AlcoholNicotine (ecig, vape, tobacco)Marijuana (edibles/oils/smoking)CocaineMethamphetamineHallucinogens (LSD/PCP/shrooms)Ecstasy/MollySteroidsStimulants (Adderall/Ritalin)Benzos (Xanax/Valium/Ativan)InhalantsHeroinOpoids (Fentanyl/Oxy/Percs)Other
PAST USE ONLY. Check any of the following that your child has EVER used in the PAST.

AlcoholNicotine (ecig, vape, tobacco)Marijuana (edibles/oils/smoking)CocaineMethamphetamineHallucinogens (LSD/PCP/shrooms)Ecstasy/MollySteroidsStimulants (Adderall/Ritalin)Benzos (Xanax/Valium/Ativan)InhalantsHeroinOpoids (Fentanyl/Oxy/Percs)Other
Has your child been treated for substance abuse? If so, when, where, and was it helpful?
Family and Supportive Relationships
Is the child adopted?

YesNo
If yes, at what age?
Circumstances of adoption/bio family information:
Are parents divorced or separated?

YesNo
If yes, how long?
Current custody/visitation arrangements?
Please tell us about child's parents and the household they spend the most time with. List primary household first and then other living situations/supportive relationships.
Father's name
Deceased?

YesNo
If yes, when/how?
Father's Education/Occupation
Relationship Quality (excellent, good, fair, etc):
Mother's name
Deceased?

YesNo
If yes, when/how?
Mother's Education/Occupation
Relationship Quality:
Please list immediate family members. Name, Age, Relationship (Aunt, Sister, etc), Quality(close, distant, fair), and if he or she lives with child.
Do you have any concerns about your child's relationship with a family member?

YesNo
If yes, please explain.
If yes, explain
Early Development
Any complications with pregnancy or birth (mother have a significant illness/alcohol use/smoked cigarettes/etc)?

YesNo
If yes, please explain.
Any problems with development or health (failure to thrive/low oxygen/delay meeting milestones such as salking, talking, reading)?

YesNo
Technology Use
How many hours per day is your child on a screen of any kind (phone/tablet/computer/tv)?
Does your child have a phone? Type yes or no.
If your child has a phone, at what age did he or she receive it?
If your child has a tablet, what age did he or she recieve it?
Does your child have any other devices? What kind?
What age did he or she receive the other device above?
What social media apps does your child use?
If your child plays video games, which ones?
Education Information
Child's school/town?
Current Grade Level
Typical grades?
Does your child have an IEP?

YesNo
IEP details:
Has your child experienced social, academic, or behavioral issues in school? Please explain in the appropriate space below:
Elementary School?
Middle school?
High school?
Legal History
Any past/current contact or involvement with the police or legal system (including DHS)? If so, explain:
What are some of your child's strengths?
Any other concerns or information you'd like to mention?
Has your child experienced social, academic, or behavioral issues in school? Please explain in the appropriate space below:
Should be Empty:

Child/Adolescent Intake

Trauma History

Family History

Substance Use

Family and Supportive Relationships

Early Development

Technology Use

Education Information

Legal History