Adolescent and Teen Intake Form

Name*

First NameLast Name

Date of Birth*

Date

Email*

example@example.com

Assigned Clinician*

What name do you prefer to be called?*

What gender pronoun do you prefer to be referred by?*

What sexual orientation do you identify with?*

What race and ethnicity do you identify as?*

Please share why you are coming to therapy? Are there any particular problems or worries that you have right now?*

Please indicate if you have ever felt any of the following feelings a lot and they became a problem for you:*

Type any other feelings not listed below

Have you ever experienced problems like this before?*

Do you ever have problems falling asleep or staying asleep?*

Do you have nightmares very often?*

What are the things that make you feel the saddest?*

Is there anything that really worries you?*

What would you like to be different or better in your life as a result of therapy?*

What are your thoughts about being in therapy? (Is this something that you asked to do or is this something your parent(s), caregiver(s), or someone else wants you to do?*

Do you have any worries about being in therapy?*

How involved would you like your parent(s) or caregiver(s) to be?*

Have you ever been in therapy before?*

If you have what did you like about it?*

If you have what did you not like about it?*

Have you ever thought about wanting to hurt yourself on purpose because of being really sad or unhappy with your life?*

Have you ever thought about wanting to commit suicide?*

If you have thought about it, did you do it? If so, how did you try to hurt yourself on purpose?*

Have you ever had to go to the hospital because of this?*

Are you currently taking any medication related to your mental health?*

Who do you currently live with?*

Please share about your parent(s) or caregiver(s).*

Are they married? Divorced? (If divorced, how old were you when they got divorced?)*

What do they do for a living?*

Do you get along with them?*

Do you have any brothers or sisters?*

If you do please share about them.*

Do you get along with your siblings?*

Do you know of any family members who have mental health issues? (If so, please elaborate)*

Do you know if any of your family members struggle with drug and alcohol use? (If so, please elaborate)*

Do you know if any of your family members have been involved in the legal system, such as being arrested or incarcerated? (If so, please elaborate)*

Are you currently dating anyone?*

If you are dating someone, how long have you been together?*

What does your family think about them?*

Do you have many friends?*

Has it ever been hard for you to make friends?*

Have you ever been bullied? (If so, did you ask for help? Did you receive help?)*

What kinds of activities do you like to do for fun?*

What grade are you currently in?*

How do you feel about school?

Has school ever been difficult for you?*

Did you ever receive any special education services (e.g. academic tutoring, IEP, classroom accommodations, etc.)? If yes, provide details.*

Did you graduate from high school or get a GED?*

Do you have a job? (If so, where do you work and how many hours per week?)*

Do you have any medical issues? (Currently or in the past)*

When was the last time you saw your physician and how did it go?*

Have you experimented with alcohol and other drugs? (If yes, please specify which substances and how old you were)*

If you answered NO to this question you can move on to the next section.

If you have, do you currently use alcohol or other drugs? (If so, how often and how much do you typically use at a time?)

Have you ever been pressured to use drugs and alcohol by others?

Have you ever been worried about your drug and alcohol use? (If so, please elaborate)

Has anyone in your life ever expressed concerns around your drug and alcohol use? (If so, please elaborate)

Have you ever received drug and alcohol treatment?

Have you ever gotten into trouble with the law due to substance use or for any other reason? (If so, please elaborate)

Have you ever had a physical fight with a family member, significant other, or another person (including throwing objects, hitting, shoving, etc.)?*

Did you ever have sexual contact with another person against your will or went along with it even though you didn’t really want to?*

Have you ever have a family member physically, sexually, verbally, or emotionally hurt you? (If so, please explain)*

Have you ever have a significant other physically, sexually, verbally, or emotionally hurt you? (If so, please explain)*

Have you ever witnessed someone else getting abused?*

Have you ever witnessed community violence?*

Have you ever felt unsafe where you live (either inside your home or in your immediate neighborhood)?*

What do you feel proud of?*

What/Who makes you feel good?*

What/Who matters to you?*

Who do you consider your "people"?*

Form

Reasons for coming to therapy

Treatment History

Family Information

Social Information

Social and Work

General Health

Substance Use

Abuse and Trauma

Strengths