YOUTH INTAKE FORM
Name of the young person?
Date of Birth and age:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School they attend:
Class they are in:
GP name and address:
Medical history:
Has your young person been linked in with a previous service: therapeutic, speech and language, occupational therapy? If yes, please explain how that was helpful or not helpful?
Are you the parent's, guardian, family member of the young person?
Mother's Name / Guardian Name
Mother's Age
Occupation
Country of Origin
Email Address
Phone Number
Father's Name / Guardian
Father's Age
Occupation
Country of Origin
Email Address
Phone Number
Does the young person have any siblings? If so please state their: NAME, AGE and a brief DESCRIPTION of their relationship.
Is there any other important people that your young person has in their life? (Extended family, childminders, close friends etc)
If parent's are still together or separated, can you please describe your relationship as a COUPLE and as CO-PARENTS.
Has anything changed in the couple/co-parent relationship recently/over the years that would be important for me to know about?
How do you as a couple navigate challenges in your relationship and in your family as parents?
How would you describe how you communicate with each other?
Has there been any significant loss or family challenges, such as, illness?
Do the parent/guardians have any diagnosis or history of anxiety, depression or any other mental health challenges/diagnosis? If YES, please explain how this impacts you in your day-to-day?
What is the family history of mental health in your extended family?
Developmental milestones – speech and language and / or fine, gross motor skills – did the young person meet their milestones or were they delayed in any way?
Socially - in school: How would you and the school describe how the young person is getting on?
Academically - in school: How would you and the school describe how the young person is getting on?
Any changes in school? Bullying? Or any other challenges?
What brings you here today?
When did you notice this change began? Has it become worse, stayed the same or improved?
How has the family tried to help/deal with these challenges?
Has the family dynamic changed since you noticed this?
Can you give an example what comes up for the young person/family AND how you as parents/guardians respond?
Was the young person doing anything before that they are not doing now?
How are you hoping this space could be useful to your family?
Is there anything else that would be important for me to know?
Submit
Should be Empty: