Adolescent Intake Form (Ages 12-17)
Personal Information
Name
First Name
Last Name
Date
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Month
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Day
Year
Date of Birth
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January
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Day
Please select a year
2025
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Year
Primary reason(s) for seeking services:
Give a brief history and development of your complains from onset to present:
Please check the severity of your problems
Mildly Severe
Moderately Severe
Very Severe
Extremely Severe
Incapacitating
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Family History
Client's Mother
Give a description of your mother's personality and her attitude towards you:
Are you able to confide in your mother?
Yes
No
Does your mother understand you?
Yes
No
Do you feel loved, respected, and accepted by your mother?
Yes
No
Is there anything notable, unusual, or stressful about your relationship with your mother?
Yes
No
If yes, please explain:
Client's Father
Give a description of your father's personality and his attitude towards you:
Are you able to confide in your father?
Yes
No
Does your father understand you?
Yes
No
Do you feel loved, respected, and accepted by your father?
Yes
No
Is there anything notable, unusual, or stressful about your relationship with your father?
Yes
No
If yes, please explain:
Give an impression of your home atmosphere:
Please describe the relationship between your parents, and if applicable, the marital relationship between your current parent(s) and step-parent(s):
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Medical History
On average, how many hours do you sleep daily?
Do you have trouble falling asleep at night or waking in the middle of the night?
Yes
No
If "yes", how long has this been a problem?
Describe your appetite (during the past week):
Poor
Average
Large
Comments on your eating habits/nutrition:
Do you use or have a problem with tobacco, alcohol, or other drugs?
Yes
No
If "yes", describe:
Please list any medications you are currently taking with the dosage amount:
List major illnesses, infectious diseases, operations, and injuries. Include the age when they occurred and the severity. Note any recent health of physical changes:
Indicate any allergies or adverse reactions you have experienced:
Have you ever experimented with any of the following?
Alcohol
Marijuana
Cigarettes
Vape
Other
Have you felt depressed recently?
Yes
No
If "yes", for how long?
Have you had any suicidal thoughts recently?
Yes
No
If yes, how often?
Frequently
Sometimes
Rarely
Have you had any suicidal thoughts in the past?
Yes
No
If "yes", how long ago?
How often?
Frequently
Sometimes
Rarely
Please explain:
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Education
Which subjects do you enjoy in school?
Which subjects do you dislike in school?
What grades do you normally receive in school?
Have there been any recent changes in your grades?
Yes
No
If "yes", please descibe:
Feelings about School Work:
Anxious
Passive
Enthusiastic
Fearful
Eager
No expression
Bored
Rebellious
Other
Approach to School Work:
Organized
Industrious
Responsible
Interested
Self-directed
No initiative
Refuses
Does only what is expected
Sloppy
Disorganized
Cooerperative
Doesn't complete assignments
Other
Performance in School:
Satisfactory
Underachiever
Overachiever
Other
If you are involved in a vocational program or work a job, please fill in the following:
What is your attitude toward work?
Poor
Average
Good
Excellent
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Religious/Spiritual Information
Do you practice religion?
Yes
No
If "yes", what is your faith?
If "no", do you consider yourself to be spiritual?
Yes
No
On a scale of 1-10, with 10 being the highest, what is your interest in spiritual growth?
Do you attend church?
Yes
No
If "yes", where and how often do you attend?
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Social History
Your Peer Relationships"
Spontaneous
Follower
Leader
Difficulty making friends
Makes friends easily
Long-time friends
Other
Do you have any problems with the following social areas?
Yes
No
Communicating Effectively
Being Aggressive
Problem with Authority Figures (teacher, law, etc)
Reluctant to Ask for Help
Long-term shyness towards adults
Assertiveness
Unwillingness to Cooperate/Share
Difficulty taking Guidance or Constructive Criticism
Sharing
Long-term shyness towards peers
Please describe any significant events you feel may have influenced your "social confidence":
Who are the important people in your life?:
What do you typically do with your unstructured time?:
Describe special areas of interest or hobbies (e.g. art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc.):
How often does your family spend time together? How are family times usually spent? What are your family's favorite activities?:
Do you get along well with others your age?
Yes
No
Do you have trouble keeping friends?
Yes
No
Have you ever hurt anyone while fighting?
Yes
No
Have you had problems with being teased or bullied?
Yes
No
Do you prefer to be alone?
Yes
No
Do you have a close friend?
Yes
No
Are you as invited/included in activities (sleepovers, parties) as much as other teens?
Yes
No
Do you spend most of your free time with older teenagers?
Yes
No
Are you up on the latest music?
Yes
No
Are you quite conscious of your clothes?
Yes
No
Are you quite conscious of your appearance or weight?
Yes
No
Do you find it easier to be friends with members of the opposite sex than those of the same sex?
Yes
No
Are you interested in the opposite sex?
Yes
No
Do you date?
Yes
No
If "yes", how old were you when you started?
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Training and Discipline
How are you disciplined by your mother?
For what reasons are you typically disciplined by your mother?
How are you disciplined by your father?
For what reasons are you disciplined by your father?
Do your parents agree on how and when to discipline?
Describe how you respond to discipline:
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Treatment Concerns and Goals
List your three main difficulties in school:
List your three main difficulties at home:
Please describe how you express anger:
Please describe how you express anxiety:
Please describe how you express happiness:
Please describe how you express sadness:
List your three of your strengths:
List your three areas needing improvement:
List your five main fears:
How do you and other family members generally handle problem behaviors?
Do you feel that your behavior is affecting other members in the family?
Yes
No
If "yes", in what ways?
Is your current behavior a noticeable change from past behavior?
Yes
No
If "yes", in what ways? For how long?
How have you previously tried to handle the problematic situation?
Have there been any significant changes or events in your life? (family, moving, fire, etc)
Yes
No
If "yes", describe:
Do you have a history or recent occurrence(s) of abuse?
Yes
No
If "yes", what kind(s)?
Verbal
Sexual
Physical
Emotional
Please state when and describe:
What family involvement would you like to see in counseling?
Any additional information that would assist us in understanding current concerns or problems?
In a few words, what do you think therapy is all about?
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Please select any of the following that apply to you:
Affectionate
Aggressive
Angry
Anxiety (nervous, tense)
Argumentative
Attractive
Avoid adults
Bad Home Conditions
Can’t do anything right
Can’t make friends
Can’t relax
Careless, reckless
Clumsy/Accident Prone
Confident
Confused
Considerate
Cooperative
Critical of self
Difficulty speaking
Don’t enjoy things
Easily frustrated
Eating disorder
Expect failure
Fearful
Full of Hate
Full of Regrets
Guilty
Generous
Headaches
Hopeful
Hopelessness
Horrible Thoughts
Impulsive
Insecure
Intelligent
Irritable
Joyful
Learning problems
Lies
“Life is empty”
Lonely
Lonely
Memory problems
Misunderstood
Morally Wrong
Mood Swings
Nightmares
Often sick
Overweight
Oversensitive
Perfectionist
Sad
Scared
Self-abusive (cutting, burning...)
Shy, timid
Skips school
Sleeping problems
Steals
Selfish
Sick often
Stomach trouble
Stubborn
Stupid
Sympathetic
Teased
Temper tantrums
Tired
Trouble sleeping
Unattractive
Unloved
Worries Excessively
Worthless
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