Therapy Intake & Consent Form

Therapy Intake & Consent Form
ONLY COMPLETE THIS FORM IF YOU HAVE RECEIVED APPROVAL FROM YOUR STUDENT'S FAMILY SCHOOL LIAISON (FSL)

Please complete all forms in its entirety. All information on this intake form is considered strictly confidential.
Student Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Age:*
Gender:*
Which category best describes the student?*

African American or BlackAmerican Indian or Native AmericanAsianCaucasian or WhiteHispanic, Latino, or Spanish OriginMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderMultiracialOther
School: *
Grade: *
Has this student received therapy services from Transform & Thrive Therapy previous to this school year?*

YesNo
If possible, would you like a Spanish speaking therapist?*

YesNo
Does the student have a 504 or an IEP?*

504IEPBothNeither
Please elaborate on services/accommodations the student receives.*
Parent/Guardian Name:*
Relationship to Student:*
Parent/Guardian Phone Number:*
Please enter a valid phone number.
Parent/Guardian Email:*
example@example.com
Contact Preference (Select all that apply):*

EmailPhoneText
Best Time to Contact (Select all that apply):*

MorningAfternoonEvening
Please describe the reason for this therapy referral.*
How distressing (upset, frustrating, stressful) is this issue for the student on a scale from 1-10? 1=not distressing, 10=most distressing*

1

2

3

4

5

6

7

8

9

10

1 is Not Distressing, 10 is Most Distressing
How long has the student been experiencing distress about this issue?*
When and how did you first notice this issue?*
Please describe any changes or incidents (such as moving, a death in the family, changes in schools, birth of a sibling, witnessed a traumatic event, etc.).*
What kinds of changes have you seen in the student (such as changes in academics, sleep, or eating patterns)?*
Please select ALL symptoms and issues you have observed from this student.*

Anxious/WorriedAnger, aggression, or violenceAttitude issuesBullying (by others)Bullying (towards others)Cutting, burning, or physically harming selfChange in eating habitsCounting or ordering or things (obsessively)Concentration or focus issuesConflicts with adults (parents, teachers, etc.)Conflicts with others (friends, other peers)Crying or tearfulDepressed moodDifficulty being aloneDisorganizedDrug or alcohol issuesEasily distractedEasily irritatedFatigued or tired oftenFears (monsters, snakes, people, etc.)Guilt feelings/shameHyperactiveImpulsiveLegal issuesLiving arrangement issuesLying frequentlyLonelyMood swingsMotivation reduced or absentPanic AttacksPerfectionismPhysical issues (stomachaches, frequent headaches, etc)School or employment issuesSelf-esteem lowSexual identify concernsSexual issuesShy or uneasy around othersSleep problemsSuicidal attemptsSuicidal thoughtsUnassertiveUnwanted behaviors or thoughtsWithdrawn or alone too much
Please elaborate on all symptoms/issues selected above.*
Developmental History

This section will ask about the student's developmental history. Please provide as many details as possible.
Was the student a full term pregnancy?*

YesNoUnknown
Were there any complications during the pregnancy or birth?*

YesNoUnknown
Please elaborate on any complications during the pregnancy or birth.*
Did the student hit developmental milestones around the appropriate age? (For example, did the student hold their bottle, sit up, crawl, walk, toilet train at the appropriate age)?*

YesNo
Please elaborate on developmental delays.*
Please describe any emotional and behavioral difficulties the student exhibited as a baby, toddler, and small child.*
Trauma History

This section will ask about the student's trauma history. Please provide as many details as possible.
Does the child have a history of abuse (physical, mental, emotional, or sexual) or trauma?*

YesNo
If yes, please select the type(s) of trauma/abuse the student has experienced.*

PhysicalSexualEmotionalVerbalDomestic AbuseNeglectHomelessnessOther
Please elaborate on all traumas selected above.*
Family History & Interaction

This section will ask about the student's family history and family interaction. Please provide as many details as possible.
Please list any cultural or religious traditions that are important in your family.*
What is your family's religious background?*
Please list any mental health history (such as ADHD, depression, anxiety, bipolar, learning disabilities, etc.) for family members (including parents, grandparents, siblings, aunts, uncles, etc.).*
Please list any substance abuse history (such as alcoholism or drug addiction) for family members (including immediate and extended members).*
Who currently lives with the student (please list names and relationship to student)?*
What do you do together as a family unit?*
How does your family express feelings?*
How are conflicts resolved in your family?*
Who is in charge of discipline in your family and what type of discipline is used? *
Psychological/Mental Health History

This section will ask about the student's mental health history. Please provide as many details as possible.
Has the student received services from a counselor, psychologist, or social worker before?*

YesNo
Please elaborate on services received and provide the service providers name and facility where services were provided.*
Is the student currently taking any medications to support their mental health?*

YesNo
If the student is currently taking medications, please list them below.*
Are you the student's legal guardian? *

YesNo
By signing your legal name, you acknowledge your receipt of "Disclosure Statement and Consent for Treatment". You also consent to your student receiving therapeutic services through Transform & Thrive Therapy. *

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Disclosure Statement and Consent for Treatment
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Therapy Intake & Consent Form

ONLY COMPLETE THIS FORM IF YOU HAVE RECEIVED APPROVAL FROM YOUR STUDENT'S FAMILY SCHOOL LIAISON (FSL)

Developmental History

Trauma History

Family History & Interaction

Psychological/Mental Health History