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*
     / /
  • Gender*
  • Format: (000) 000-0000.
  • Birth Date*
     / /

  • Family Information

  • I live with my:*
  • Have you ever lived in another place?*

  • Medical Information:

  • Date last seen?*
     / /
  • Have you ever been to a counselor?*
  • Are you seeing another counselor now?*
  • Do you have frequent nightmares?*
  • Choose the words below that best describe how you usually feel?*
  • Do you think you are a problem at school?*
  • Do you think you are a problem at school?*
  • Do you think that they are clear?*
  • Do you think it is fair?*
  • Do you get your feelings hurt easily?*
  • Do you lose your temper easily?*

  • 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?*
  • Do you wish you had more friends?*
  • How often do you go to church?*
  • Would you say you have a relationship with Jesus?*
  • Should be Empty: