Child Intake Evaluation

Child Intake Evaluation
Please fill out the document below and click "Submit" when complete.
1. IDENTIFYING INFORMATION
Child's name*

First NameLast Name
Child's Preferred Name
Custodial parent name(s)

First NameLast Name
Custodial parent name (alt)

First NameLast Name
Today's date

MonthDayYear
Date
Referred by
Gender
How does the child identify?
Age
Preferred Pronouns
Birth date*

MonthDayYear
Date
Email address
primary email contact
Home address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone number
HomeFormat: (000) 000-0000.
Child (cell)
Child (cell)Format: (000) 000-0000.
Mother (cell)
Mother (cell)Format: (000) 000-0000.
Father (cell)
Father (cell)Format: (000) 000-0000.
Reminder call*
Preferred number
Reminder (type)
Preferred contact type
School
School name
Phone (School)
PhoneFormat: (000) 000-0000.
Grade in school
Emergency contact

First NameLast Name
Emergency contact (phone)
PhoneFormat: (000) 000-0000.

Immediate Family Living Outside the Home
Does the child have immediate family living outside the home?

YesNo
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
- Relationship to client
- Add another?
  
  YesNo
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
- Relationship to client
- Add another?
  
  YesNo
- Name
  
  First NameLast Name
- Date of birth
  
  MonthDayYear
- Relationship to client

Insurance Information
Name of subscriber

First NameLast Name
Relationship
Relationship of client to subscriber
Date of birth

MonthDayYear
Employer
Address (subscriber)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance company
Phone
Format: (000) 000-0000.
Address (insurance)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Identification number
Group number
Do you have secondary insurance?

YesNo
- Name of subscriber
  
  First NameLast Name
- Relationship
  Relationship of client to subscriber
- Date of birth
  
  MonthDayYear
- Employer
- Address (subscriber)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Secondary insurance
- Phone
  Format: (000) 000-0000.
- Address (insurance)
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Identification number
- Group number

Patient or Authorized Person's Signature
I authorize the release of any medical or other information necessary to process a claim. I also request payment of government benefits either to myself or to the party who accepts assignment. I authorize payment of medical benefits to provider of services.
Signature (Insured)*
Name (print)*

First NameLast Name
Date*

MonthDayYear
Date

3. PRIOR COUNSELING
Have you worked with the child's teacher of school counselor?

YesNo
Name of teacher or counselor

First NameLast Name
Date

MonthDayYear
from
Date (school counseling)

MonthDayYear
to
Describe what happened

0/50
Has the child been in counseling before?

YesNo
Who did you see?

First NameLast Name
Dates

MonthDayYear
From
Dates

MonthDayYear
To
Describe what happened

0/50
Did the child receive counseling prior to this?

YesNo
Who did you see?

First NameLast Name
Dates

MonthDayYear
From
Dates

MonthDayYear
To
Describe what happened

0/50
Has the child been prescribed any psychiatric medications?

YesNo
Please Describe

0/50

7. SCHOOL HISTORY
When did the child start school?

MonthDayYear
Were there any problems when the child started school?

YesNo
What problems have come up during the school years?

0/35
What grades is the child getting?

0/35
Describe any changes in the child's school performance

0/35
How does the child get along with their teachers?

0/35
How does the child get along with their friends or peers in school?

0/35
What are the child's favoring subjects or school activities?

0/35
Should be Empty: