Child/Adolescent Intake Information

Please fill out this evaluation completely. Your information will be held in strict confidence according to NC confidentiality laws and statute.

Child’s full name: ___________________________________________ Today’s Date:__________________

Date of birth: _____________________ Gender: M☐F☐ Race/Ethnicity: ______________________

Adult providing information today: __________________________________________________________

Child lives with: ☐Both Parents☐Mother☐Father☐Grandparent/s☐Other: __________

Child’s Legal Guardian/s: ___________________________________________________________________

Child’s Primary Address: ___________________________________________________________________

Child’s Primary Phone #: ______________________________ Who does phone belong to? __________

Child’s Pediatrician: _____________________________________________ Phone: ___________________

Referred by: ______________________________________________________________________________ Parent’s Demographics Current Caretakers: Mother’s name: ___________________________

Age: _____________

Full address: ______________________________

__________________________________________

Phone #’s: ________________________________

Email Address: ____________________________

Occupation: ______________________________

Employer: ________________________________

Highest level of education completed: _______

__________________________________________

Father’s name: ____________________________

Age: _____________

Full address: ______________________________

__________________________________________

Phone #’s: ________________________________

Email Address: ____________________________

Occupation: ______________________________

Employer: ________________________________

Highest level of education completed: _______

__________________________________________

*List EMERGENCY CONTACT with full name, relationship, and telephone number/s: __________________________________________________________________________________________

2

If child resides with someone other than biological parents (adoptive parent, foster parent, relative, biological mother and step-father, etc.), please explain this arrangement in detail: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list all individuals living in your child’s home, who these individuals are in relation to your child, and each individual’s age: __________________________________________________________________________________________

__________________________________________________________________________________________

Please note if you have any particular religious or spiritual beliefs that you would like me to be aware of, or incorporate into the counseling process: __________________________________________________________________________________________

__________________________________________________________________________________________

Presenting Issues Please indicate which of these issues are concerning you and your child today: ____ Depression, unhappiness ____ Few friends, loneliness ____ Anxiety/worry/nervousness ____ Social skill problems ____ Panic attacks ____ Anger management ____ Phobia(s) ____ Alcohol or substance abuse ____ Perfectionism ____ Academic performance problems ____ School behavior problems ____ Grief or Loss ____ Memory difficulties ____ Trauma ____ Family Conflict

____ Disorganization ____ Mood swings ____ Difficulty concentrating ____ Irritability ____ Procrastination ____ Lack of assertiveness ____ Time management problems ____ Sleep problems ____ Conflicts with parents ____ Appetite issues (over/under eating) ____ Lack of Self-esteem ____ Body image concerns ____ History of abuse ____ Excessive video game use ____ Bed wetting/Withholding bowels

Please list your child’s strengths and/or areas of success: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

3

Please elaborate on the concerns you have about your child and how long you have been concerned: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please explain any high-risk behaviors your child may be currently engaging in or has engaged in in the past (i.e. aggressive behavior, drug/alcohol use, sexual activity, running away, etc.) __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please explain any legal problems your child currently has, or has had in the past (involvement with Juvenile Justice, court, probation, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

If applicable, please list any activities outside of school (sports teams, dance, church, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

Please state all methods of discipline you use with your child and if these methods have been successful: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please state what you hope to achieve, improve or make different through counseling: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

4

Family Dynamics Please list all applicable disorders and/or conditions within your child’s biological family structure, including those of siblings, parents, grandparents, aunts/uncles, cousins, etc. (i.e. depression, anxiety, substance abuse, genetic disorders, neurological disorders, emotional/physical/sexual abuse, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please state if there have been any recent stressors or changes in your environment that may be affecting your child (divorce or marital problems, death in the family, move to a new home/school/neighborhood, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Child’s Developmental and Medical History Please list any problems during pregnancy and/or delivery of your child: __________________________________________________________________________________________

__________________________________________________________________________________________

Please state if your child was exposed to in utero stressors (i.e. mother under emotional stress, cigarettes, alcohol, or drugs while pregnant, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

Please classify your child’s early temperament (i.e. easy, quiet, stubborn, shy, difficult, active, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

Please list any developmental delays or problems your child had as an infant/toddler (i.e. weaning, walking, sitting up alone, toilet training, talking, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

5

Please list any problems your child has had, or currently has, with sleep, eating habits, elimination (i.e. difficulty with urination, bowel movements, soiling undergarments, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

Please list any medical conditions your child currently has, or has had in the past (i.e. ear infections, allergies, etc.): __________________________________________________________________________________________

__________________________________________________________________________________________

Please detail all of your child’s ER visits, hospitalizations, and surgeries (including child’s age, reason, and length of stay): __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please list any medications your child routinely takes, or has taken in the past, and the reason for this medication: __________________________________________________________________________________________

__________________________________________________________________________________________

Last time your child had a physical exam: ____________________________________________________

Other Providers for Child (if applicable): Please list all current providers/agencies your child is involved with for counseling or mental health purposes. Please list the name of provider, telephone number, and what services you and/or your child are receiving: __________________________________________________________________________________________

__________________________________________________________________________________________

Please list any former providers/agencies who have seen you and/or your child for counseling or mental health treatment, including prior diagnoses your child received, when these services were received and from whom: __________________________________________________________________________________________

__________________________________________________________________________________________

6

Child’s School History Please state your child’s current grade, school, and primary teacher: _____________________________

__________________________________________________________________________________________

Please explain any identified special needs your child has at his/her school (i.e. 504 or IEP, psychoeducational testing results, etc.): ______________________________________________________ __________________________________________________________________________________________

__________________________________________________________________________________________

Please detail your child’s school history below: Place Date Location Concerns/Problems? Reason for Leaving Daycare

Preschool

Kindergarten

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Grade 7

Grade 8

Grade 9

Grade 10

Grade 11

Grade 12

Is there anything else you would l ike me to know? What else would be helpful for your child in therapy? Please l ist ANY concerns or questions: __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________