Adolescent Intake Form (Ages 12-17)

  • Adolescent Intake Form (Ages 12-17)

  • Personal Information
  • Date
     - -
  • Please check the severity of your problems

  • Family History

  • Client's Mother
  • Are you able to confide in your mother?
  • Does your mother understand you?
  • Do you feel loved, respected, and accepted by your mother?
  • Is there anything notable, unusual, or stressful about your relationship with your mother?

  • Client's Father
  • Are you able to confide in your father?
  • Does your father understand you?
  • Do you feel loved, respected, and accepted by your father?
  • Is there anything notable, unusual, or stressful about your relationship with your father?

  • Medical History
  • Do you have trouble falling asleep at night or waking in the middle of the night?
  • Describe your appetite (during the past week):
  • Do you use or have a problem with tobacco, alcohol, or other drugs?
  • Have you ever experimented with any of the following?

  • Have you felt depressed recently?
  • Have you had any suicidal thoughts recently?
  • If yes, how often?
  • Have you had any suicidal thoughts in the past?
  • How often?

  • Education
  • Have there been any recent changes in your grades?
  • Feelings about School Work:

  • Approach to School Work:

  • Performance in School:

  • If you are involved in a vocational program or work a job, please fill in the following: 

  • What is your attitude toward work?

  • Religious/Spiritual Information
  • Do you practice religion?
  • If "no", do you consider yourself to be spiritual?
  • Do you attend church?

  • Social History
  • Your Peer Relationships"

  • Rows
  • Do you get along well with others your age?
  • Do you have trouble keeping friends?
  • Have you ever hurt anyone while fighting?
  • Have you had problems with being teased or bullied?
  • Do you prefer to be alone?
  • Do you have a close friend?
  • Are you as invited/included in activities (sleepovers, parties) as much as other teens?
  • Do you spend most of your free time with older teenagers?
  • Are you up on the latest music?
  • Are you quite conscious of your clothes?
  • Are you quite conscious of your appearance or weight?
  • Do you find it easier to be friends with members of the opposite sex than those of the same sex?
  • Are you interested in the opposite sex?
  • Do you date?

  • Training and Discipline

  • Treatment Concerns and Goals
  • Do you feel that your behavior is affecting other members in the family?
  • Is your current behavior a noticeable change from past behavior?
  • Have there been any significant changes or events in your life? (family, moving, fire, etc)
  • Do you have a history or recent occurrence(s) of abuse?
  • If "yes", what kind(s)?

  • Please select any of the following that apply to you:
  • Should be Empty: