Gibson Intake Form
Please be sure to fill out the entire form and press the "Submit" button at the end
Client
Today’s Date
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Month
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Day
Year
Date
Date of Birth
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Month
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Day
Year
Date
Child’s Age
Grade
Child’s Age
School
Parents
Person Completing Form
I. PRESENTING PROBLEM:
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II. FAMILY HISTORY:
A. Family Composition
Relationship
Name
Age
Education
Employment
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2
3
4
5
6
7
8
9
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B. Marital History (give number/length of marriages, divorce-reason, present marital status
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III. CLIENT'S DEVELOPMENTAL/HEALTH HISTORY
A. Mother’s pregnancy, labor and delivery history
Adopted
Planned
High blood pressure
Morning sickness
Excess weight gain
Cigarettes
Alcohol
Prescribed medications
Other drugs
Toxemia
Eclampsia
Vaginal bleeding
Edema
Infections
Bed rest
Hospitalizations
COMMENTS
Labor
Full term
Premature
Induced
Medication
List
Delivery
Vaginal
Cesarean
Forceps
Cesarean Explain
COMMENTS
B. Child’s birthweight
C. Birth Complications/Treatment
D. Place of Birth
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IV. DEVELOPMENTAL HISTORY
Milestones/ages attained:
Turned over
Sat alone
Crawled
Walked assisted
Walked alone
First Sounds
First words
Simple sentences
Bladder trained
Bowel trained
COMMENTS
Developmental delays
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V. CHILDHOOD DIFFICULTIES
(when, how often, last episode and treatment)
A. Enuresis
B. Encopresis
C. Eating Patterns
Breast fed
How long?
Formula/type
Age weaned
Past appetite
Present appetite
COMMENTS
D. Sleeping Patterns (Nightmares, sleepwalking, difficulty going to sleep, insomnia, etc.)
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VI. MEDICAL HISTORY
Ages, treatment, last occurrence
A. Illnesses (esp. fevers, ear infections, seizures, etc.)
B. Accidental Injuries – Age, injury, how, medical treatment – where and by whom
C. Hospitalizations - age, why, where and length of stay
D. Medications (age, type, dosage, when prescribed and discontinued)
1. Past
2. Present
3. Effectiveness of medications prescribed for behavioral/emotional issues
E. Physicians (Pediatricians, Family Practitioner, Neurologist, etc, date of last visit):
F. Speech/Language, hearing, vision screening and/or evaluations (include dates, where, results, treatment and/or recommendations
G. Family Physical, Mental Health History
H. Other Community Agencies Involved: (i.e. CMS, TPF, DCF, DS, UCP, etc.) Give dates, services received and outcome)
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VII. EDUCATIONAL HISTORY
List all schools and grades attended, academic difficulties, retentions,suspensions, absences, special classes and results, behavioral difficulties
A. Previous psychological evaluations (give testing/therapy dates, by whom, results and recommendations)
B. Previous tutoring, counseling, or therapy (give dates, with whom and recommendations)
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VIII. QUALITY AND NATURE OF RELATIONSHIPS
Mother
Father
Peers
Siblings
Significant Others (parent, boyfriend/girlfriend, grandparents, family friends, etc.)
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IX. ACTIVITIES
A. Client's Interests/Play Activites (Formal and Informal)
B. Client's Interests/Play Activites (Formal and Informal)
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X. BEHAVIOR AND MANAGEMENT TECHNIQUES
A. Discipline (Identify primary disciplinarian, typical methods, effectiveness)
B. Specific Behavior Problems (Explain any that you select using the boxes that appear below)
Easily distracted
Overly active
Daydreams
Demanding
Easily frustrated
Quick to Anger
Fighting
Truancy
Suspensions
Vocal noise
Body tics, twitches
Set fires
Fears/Phobias
Cruelty to animals
Cruelty to animals
Substance use/abuse
Easily distracted
Overly active
Daydreams
Demanding
Easily Frustrated
Quick to Anger
Fighting
Truancy
Suspensions
Vocal noise
Body tics, twitches
Set fires
Fears/Phobias
Cruelty to Animals
Substance use/abuse
Describe child's personality
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XI. INCIDENCE OF NEGLECT, PHYSICAL OR SEXUAL ABUSE
(when, what happened, by whom, reported/unreported, outcome)
XII. OTHER COMMENTS
XIII. WHAT WOULD YOU LIKE TO SEE HAPPEN AS A RESULT OF THIS EVALUATION?
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