CKHC Behavioral Health Intake Form

Behavioral Services Intake Form

Coastal Kids Home Care
Date*

MonthDayYear
Date
Services for:*

Adult (for bereavement support)Child/Youth (ages 5 to 21)
Service Requested
Papillon- Group Support for Adults
  *
CKHC- Individual Counseling (ages 5-21)*
Format Requested

TelehealthIn Person
Client Information
Client Name*

First NameLast Name
DOB*

MonthDayYear
Date
Name of referring person*

First NameLast Name
Relationship to client*
Client Insurance Type*
Client Member ID
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Client Preferred Language*

EnglishSpanish
Parent/Guardian Preferred Language*

EnglishSpanish
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Gender*
Client Race*
Name of current school
Emergency Contact
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Relationship to client
Preference Time/Location
Time Preference for service
Day preference for service
Location preference
Treatment History
Have you ever received therapy

YesNo
Type of Therapy received

In-patientOut patient
Provider/Organization name
Diagnosis given (If applicable)
Did you receive medication related to treatment

YesNo
Has the client ever needed to be hospitalized due to mental health reason.

YesNo
Has the client had any Suicidal ideation

YesNo
If yes, please explain
Stressful Life Events
Stressful life events that have affected the client and/or family

Economic ProblemsDifficulty accessing health careLegal issues or crimeIssues related to cultural values or beliefsFamily conflict or lack of supportSocial problemsEducational or occupational difficultiesHousing problemsGrief or BereavementOther
If you selected any Stressful Life Events above, please elaborate below
Symptoms/Behaviors
Reason you are seeking services for your child. *
Anything else you would like to share with the therapist.
Should be Empty:

Behavioral Services Intake Form

Client Information

Emergency Contact

Preference Time/Location

Treatment History

Stressful Life Events

Symptoms/Behaviors