Adolescent Intake Form

Adolescent Intake (15 & under)

1948 N Plaza Dr. Rapid City, SD 57702
Please fill out this questionnaire as completely as possible. Your information will be kept confidential.
Date*

MonthDayYear
Date
Parent(s)*
Name*

First NameLast Name
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
How long have you lived here?*
Age*
Birth Date*

MonthDayYear
Date
Grade*
School Name*
Family Information
I live with my:*

Birth FatherBirth MotherStepfatherStepmotherAdoptive FatherAdoptive MotherOther
Number of Brothers*
Brothers Age(s)
Number of Sisters*
Sisters Age(s)
Number of Half/Stepbrothers*
Half/Stepbrothers Age(s)
Number of Half/Stepsisters*
Half/Stepsisters Age(s)
Have you ever lived in another place?*

NoYes
If yes, where?*
Medical Information:
Doctor's Name*
Date last seen?*

MonthDayYear
Date
List any medical conditions or problems:*
List any medication that you take:*
Have you ever been to a counselor?*

NoYes
When did you see them?*
Why did you see the counselor?*
Are you seeing another counselor now?*

NoYes
If yes, who?*
What is the best thing that ever happened to you?*
What is the worst thing that ever happened to you?*
Do you have frequent nightmares?*

YesNo
If yes, please explain:*
Who is the person who understands you best?*
Choose the words below that best describe how you usually feel?*

AnxiousHappyHurtSadMadAfraidOther
When do you usually feel this way?*
What do you usually do when you feel this way?*
How do you feel about your school grades?*
How do your parents feel about your school grades?*
Do you think you are a problem at school?*

YesNo
If yes, why?*
Do you think you are a problem at school?*

YesNo
If yes, why?*
If you could change two things at home, what would they be?*
What do you do to help around the house?*
How do you feel about the rules at home? (phone usage / friends / grades, etc.)*
Do you think that they are clear?*

YesSometimesNo
If no, what do you think would help?*
If you have a phone or device what are your most used apps?*
Has screen time/phone usuage caused conflict in any relationships? Explain:*
How are you disciplined at home?*
Do you think it is fair?*

YesNo
If no, how do you wish it were different?*
What do you have the most trouble with at home?*
Do you get your feelings hurt easily?*

YesNo
If yes, when and how?*
Do you lose your temper easily?*

YesNo
If yes, when?*
Do you think that they are clear? If no, what do you think would help?

If you have a phone/device what are your most used apps?
Do you have a close friend?*

YesNo
Do you wish you had more friends?*

YesNo
What do you like to do with your friends?*
What kind of things does your family do together?*
What kinds of things do you wish your family did together?*
If you could change one thing about yourself, what would it be?*
How often do you go to church?*

WeeklyMonthlySeldomNever
Where do you go to church?*
Would you say you have a relationship with Jesus?*

YesUnsureNo
If yes, how did you become a Christian?*
How has knowing God made a difference in your life?*
What helps you grow closer to God?*
Give one reason you think you are here at Christian Life Ministries.*
Why do you think your parents want you here?*
How can we help?*
Should be Empty:

Adolescent Intake (15 & under)

Please fill out this questionnaire as completely as possible. Your information will be kept confidential.

Family Information

Medical Information: