Child Intake Form for Parents and Caregiver

Child Intake Form for Parents and Caregiver
Child's Name*

First NameLast Name
Email
example@example.com
Child's Date of Birth*

MonthDayYear
Date
Parent or Caregiver Full Name*

First NameLast Name
Parent or Caregiver Phone Number*

Area CodePhone Number
Parent or Caregiver Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Caregiver Email (if different than the child's)*
example@example.com
Child's Assigned Clinician*
Please share why your child is coming to therapy

Are there any particular problems or worries that they have been expressing to you? Do you have any specific concerns of your own about your child?
Please indicate if you have observed or if your child has vocalized having any of the following feelings on a more regular basis that has caused concern.*

SadnessFeeling hopelessLonelinessAnxiety and worryScaredAnger
Other feelings: Have they expressed that they are experiencing any other feelings?*
Have they ever experienced problems like this before?*
Do they ever have problems falling asleep or staying asleep?

YesNoOther
Do they have nightmares very often?*
What are the things that they have vocalized that make them feel the saddest?*
Is there anything that really worries them that you are aware of?*
What would you like to see be different or better in your chid’s life as a result of therapy?*
What are their thoughts about being in therapy?*
Is this something that they had requested on their own or something that you wanted them to do due to the concerns you have about them?*
What are your thoughts about them being in therapy?*
Do you have any concerns or worries about them being in therapy?*
Treatment History
Has your child ever been in therapy before?*
If so, what did they vocalize liking about it?*
If so, what did they vocalize not liking about it?*
Has your child ever expressed thoughts of wanting to hurt themselves? If so, did they act on it? (Please elaborate)*
Has your child ever been hospitalized for mental health issues? If so, please describe what led to the hospitalization, when it occurred, and any other information that would be helpful for the therapist to know about).*
Is your child currently taking any medication related to their mental health?*
If so, please list the medications below:*
Family Information
Who does your child currently live with?*
Are you and the child’s other parent married? Divorced? (If divorced, how old were they when you got divorced? How did your child respond? Are both parents involved?)*
What do you do for a living?*
How would you describe your relationship with your child?*
Does your child have any siblings?*
If so, do they get along with them?*
Do you know of any family members who have mental health issues? (If so, please elaborate)*
Social Information
Is your child currently dating anyone?*
If so, how long have they been together?*
What do you think about your child’s significant other if they have one?*
Does your child have many friends?*
Has it ever been hard for them to make friends?*
Has your child ever been bullied? (If so, did they ask for help? Did they receive help?)*
What kinds of activities does your child enjoy doing for fun?*
School and Work
What grade is your child currently in?*
How does your child feel about school?*
Has school ever been difficult for them?*
Has your child ever received any special education services (e.g. academic tutoring, IEP, classroom accommodations, etc.)? If yes, provide details.*
Did your child graduate from high school or get a GED (if age appropriate)?*
Does your child have a job (if age appropriate)? (If so, where do they work and how many hours per week?)*
General Health
Does your child have any medical issues? (Currently or in the past)*
When was the last time your child saw their physician and how did it go?*
Substance Use
Has your child ever 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 they have, do they currently use alcohol or other drugs? (If so, how often and how much do they typically use at a time if you are aware?)
Have they ever shared about being pressured to use drugs and alcohol by others?
Have you ever been worried about their drug and alcohol use? (If so, please elaborate)
Has your child ever received drug and alcohol treatment? (If so, please state when, the duration, and the results of the treatment)
Has your child ever gotten into trouble with the law due to substance use or for any other reason? (If so, please elaborate)
Abuse and Trauma
Has your child ever had a physical fight with a family member, significant other, or another person (including throwing objects, hitting, shoving, etc.)?*
Has your child ever had sexual contact with another person against their will or went along with it even though they didn’t really want to?*
Has a family member physically, sexually, verbally, or emotionally hurt your child? (If so, please explain)*
Has your child ever had a significant other physically, sexually, verbally, or emotionally hurt them? (If so, please explain)*
Has your child ever witnessed someone else getting abused?*
Has your child ever witnessed community violence?*
Has your child ever felt unsafe where you live (either inside your home or in your immediate neighborhood)?*
Has your child ever experienced any significant losses such as the death of a family member, friend, etc.? (If so, please elaborate)*
Strengths
What are you most proud of your child for?*
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Child Intake Form for Parents and Caregiver

Please share why your child is coming to therapy

Treatment History

Family Information

Social Information

School and Work

General Health

Substance Use

Abuse and Trauma

Strengths