CHILD & ADOLESCENT COUNSELING INTAKE FORM

CHILD & ADOLESCENT COUNSELING INTAKE FORM

Thank you for entrusting us with your child’s care. This intake form helps us understand your child’s background, emotional and spiritual needs, and current concerns so counseling may be provided wisely, compassionately, and biblically. Please complete this form honestly and thoroughly. All information is treated with care and confidentiality.
SECTION 1: CHILD INFORMATION
Child’s Full Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
Gender:
School Name:
Grade:
Home Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name(s):

First NameLast Name
Parent/Guardian Name(s):

First NameLast Name
Phone Number(s):
Please enter a valid phone number.Format: (000) 000-0000.
Phone Number(s):
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Referred by (if applicable):
SECTION 2: FAMILY INFORMATION
Parents’ marital status:
Who does the child live with?
List all people living in the household and their relationship to the child:
SECTION 3: CHILD’S HEALTH, DEVELOPMENT, & BEHAVIOR
Describe any physical health concerns, diagnoses, developmental delays, or medications:
Has your child received previous counseling, therapy, or special education services?
If yes, with whom and for what reason?
Describe your child’s strengths, gifts, and interests:
Describe your child’s challenges, struggles, or concerning behaviors:
Have there been any recent changes, losses, transitions, or traumatic experiences?
If yes, please explain (as you are comfortable):
SECTION 4: SPIRITUAL BACKGROUND
Is your child familiar with Christian faith, Scripture, prayer, or church?
If yes, briefly describe their understanding or exposure:
Do you and your family attend a church?
If yes, where:
Would you like biblical principles and Scripture integrated into your child’s counseling?
SECTION 5: TEMPERAMENT

Temperament is the God-given design that influences how a child relates, responds emotionally, and processes experiences. We utilize the Arno Profile System (APS) developed by the National Christian Counselors Association, to understand temperament in three areas: inclusion – social orientation, control – decision-making, and affection – deep relationships. This understanding helps counseling be more precise, compassionate, and biblically tailored.
Has your child ever taken a temperament assessment?
If yes, which one or through which provider?
What is your understanding of your child’s temperament?
SECTION 6: CHILD’S STATEMENT (if age-appropriate)
Why do you think you’re coming to counseling, and what do you hope will happen?
SECTION 7: PARENTAL CONSENT & AGREEMENT

I affirm that the information I have provided is accurate to the best of my knowledge. I understand that counseling services provided through Miguelina Belle Christian Counseling are pastoral and biblical in nature and are not state licensed mental health, medical, or psychiatric treatment. I give informed consent for my child to receive biblical counseling and pastoral care.
Parent/Guardian Signature:
Date

MonthDayYear
Date
Printed Name:

First NameLast Name
OPTIONAL: EMERGENCY CONTACT
Name

First NameLast Name
Relationship to Child:
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty:

CHILD & ADOLESCENT COUNSELING INTAKE FORM

SECTION 1: CHILD INFORMATION

SECTION 2: FAMILY INFORMATION

SECTION 3: CHILD’S HEALTH, DEVELOPMENT, & BEHAVIOR

SECTION 4: SPIRITUAL BACKGROUND

SECTION 5: TEMPERAMENT

SECTION 6: CHILD’S STATEMENT (if age-appropriate)

SECTION 7: PARENTAL CONSENT & AGREEMENT

OPTIONAL: EMERGENCY CONTACT