Adolescent/Child Intake Form
Name
Date
/
Month
/
Day
Year
Date
Describe the problem that brought you here today
Please check all your child’s behaviors and symptoms that you consider problematic
Distractibility
Change in appetite
Visual hallucinations
Manipulative behavior
Hyperactivity
Withdrawal from people
Defiance
No/few friends
Impulsivity
Anxiety/worry
Aggression/fights
Eating problems
Boredom
Panic attacks
Homicidal thoughts
Sleep problems
Poor memory/confusion
Fear away from home
Frequent arguments
Nightmares
Sadness/depression
Social discomfort
Irritability/anger
Toileting problems
Hopelessness
Phobias
Peer/sibling conflict
Fire setting
Thoughts of death
Obsessive thoughts
Stealing
Work/school problems
Self-harm behaviors
Compulsive behavior
Destroys property
Legal problems
Crying spells
Racing thoughts
Running away
Sexual behavior
Loneliness
Wide mood swings
Swearing
Computer addiction
Low self worth
Suspicion/paranoia
Curfew violations
Alcohol/drug use
Fatigue
Hearing voices
Lying
Lack of motivation
Recurring, disturbing memories
Other
Are your child’s problems affecting any of the following?
Handling everyday tasks
Self esteem
Relationships
Hygiene
Health
Recreational activities
Work/School
Housing
Legal matters
Finances
Has your child ever had thoughts, made statements, or attempted to hurt him/herself?
No
Yes
If yes, please describe:
Has you child ever had thoughts, made statements, or attempted to hurt someone else?
Yes
No
If yes, please describe:
Has your child recently been physically hurt or threatened by someone else?
Yes
No
If so, please describe:
Has your child gambled in the past 6 months? If yes, let us know the following
Yes
No
Has your child ever felt the need to bet more and more money?
Yes
No
Has your child ever had to lie to people about how much your child has gambled?
Yes
No
FAMILY AND DEVELOPMENTAL HISTORY
Family Relationships
Name
Lives With Child?
Age
Quality of Relationship
Mother
Father
Stepmother
Stepfather
Siblings
Other Relatives
Other Relatives
Other Relatives
Other Relatives
Other Relatives
Family/Mental Health Problems
Who?
Hyperactivity
Sexually Abused
Depression
Manic Depression
Suicide
Anxiety
Panic Attacks
Obsessive-Compulsive
Anger/Abusive
Schizophrenia
Eating Disorder
Alcohol Abuse
Drug Abuse
Family Status
Parents legally married or living together
Parents temporarily separated
Father Remarried
Mother Remarried
Parents divorced or permanently separated
Number of times mother and/or father remarried
Please check if your child has experienced any of the following types of trauma or loss:
Emotional abuse
Neglect
Lived in a foster home
Sexual abuse
Violence in the home
Multiple family moves
Physical abuse
Crime victim
Homelessness
Parent substance abuse
Parent illness
Loss of a loved one
Teen pregnancy
Placed a child for adoption
Financial problems
Were there any medical problems during the pregnancy or birth of your child? If yes, please describe:
Did the biological mother use any tobacco, medication, street drugs or alchohol while pregnant with this child?
Yes
No
If yes, please describe substances used, quantity, and frequency.
Did your child have any developmental delays in early childhood crawling, walking, talking, toileting, etc? If yes, please describe
Yes
No Did your child have any developmental delays in early childhood crawling, walking, talking,
If yes, please describe
PREVIOUS MENTAL HEALTH TREATMENT
Type a question
Yes
No
When?
Provider/Program
Outpatient Counseling
Medication (Mental Health)
Psychiatric Hospitalization
Drug/Alcohol Treatment
Self-Help/Support Groups
Outpatient Counseling
School Information
Current grade/placement
This year's school grades
Excellent
Good
Fair
Poor
Past School Grades:
Excellent
Good
Fair
Poor
This year's school behavior:
Excellent
Good
Fair
Poor
This year's school behavior:
Excellent
Good
Fair
Poor
Has your child had any of the following difficulties at school?
Suspension
Incomplete homework
Learning problems
Referrals or detentions
Poor grades
Teased or picked on
Speech problems
Attendance problems
Gang influence
Does your child have an after-school provider?
Yes
No
If so, who?
Has your child ever repeated or skipped a grade?
Yes
No
If yes, which one(s)?
Has your child ever received Special Education services?
Yes
No
If yes, please describe services received and reason for services.
What does your child’s teacher(s) say about him/her?
SUBSTANCE USE HISTORY (for ages 12 and older or if applicable)
Y
N
Frequency
Amount
Y
N
Frequency
Amount
Tobacco
Caffeine
Marijuana
Cocaine/crack
Ecstasy
Heroin
Inhalants
Methamphetamines
Pain Killers
PCP/LSD
Steroids
Tranquilizers
Alcohol
Has your child had withdrawal symptoms when trying to stop using any substances?
Yes
No
If yes, please describe
Has your child ever had problems with work, relationships, health, the law, etc. due to his/hersubstance use?
Yes
No
If yes, please describe
MEDICAL INFORMATION
Date of last physical exam
/
Month
/
Day
Year
Date
Has your child experienced any of the following medical conditions during his/her lifetime?
Allergies
Asthma
Headaches
Stomach aches
Chronic pain
Surgery
Serious accident
Head injury
Dizziness/fainting
Meningitis
Seizures
Vision problems
High fevers
Diabetes
Hearing problems
Ear infections
Miscarriage
Abortion
Sleep disorder
Sexually transmitted disease
Other
Please list any CURRENT health concerns
Current prescription medications
None
See below
Current prescription medications
Medication
Dosage
Date First Prescribed
Prescribed By
Current
Current
Current
Current over-the-counter medications including vitamins, herbal remedies, etc
Allergies and/or adverse reactions to medications
None
If yes, please list below:
Allergies and/or adverse reactions to medications:
INTERPERSONAL/SOCIAL/CULTURAL INFORMATION
Please describe your child’s social support network (check all that apply)
Family
Neighbors
Friends
Students
Co-workers
Support/Self-Help Group
Community Group
Religious/Spiritual Center
To which cultural or ethnic group does your child belong?
If your child is experiencing any difficulties due to cultural or ethnic issues, please describe
How important are spiritual matters to your child?
Not at all
Little
Somewhat
Very much
Would you like spiritual/religious beliefs to be incorporated into your child’s counseling?
Yes
No
Please describe your child’s strengths, skills, and talents
Describe any special areas of interest or hobbies (art, books, physical fitness, etc.)
LEGAL INFORMATION
If the parents are separated or divorced, what is the current child custody/visitation arrangement?
Is your child currently the subject of a custody case?
Yes
No
Has your child ever been a ward of the court with SCF/DCFS guardianship?
Yes
No
Does your child have any legal offenses on record or pending in the courts?
Yes
No
By signing below, you are acknowledging and consenting to all information, practices and policies listed above. By submitting this form you acknowledge and consent to this information being securely transmitted to your assigned provider.
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