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Family Counseling Intake Form
Child/Adolescent
Client #____________
Client Name____________________________ Date_______________
Preferred Name____________ Marital Status_______________ Date of
Birth________________
Gender________________ Race____________
Ethnicity______________Address_________________________________________________________________________________________________________
Contact Information (please circle preferences for appointment
reminders)
Home__________________________ Cell___________________________
Work_____________________________
Email____________________________________________________________________________________________________
Please check all problems that you are seeking counseling
for:
Anxiety Family Conflict
Depression Occupational Problems
Trauma Physical/Medical Problems
Childhood Trauma School/Academic Problem
Attention/Concentration Difficulties Stress
Child/Adolescent Behavior Problems Substance Abuse
Developmental Concerns Eating Disorder
Difficulty with Social Interactions Verbal/Physical
Aggression
Grief Spouse/Partner Conflict
Parenting Problems Other:
Please provide brief description of any checked problems
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
These questions are for the client, however, please let your
therapist know privately if you would
answer yes to any of these questions.
Have you wished you were dead or wished you would go to sleep
and not wake up?
_________________________________________________________________________________________________________
Have you actually had any thoughts of killing yourself?
_________________________________________________________________________________________________________
Have you ever done anything, started to do anything, or prepared
to do anything to end
your life? If yes, how long ago did you do any of these
things?_________________________________________________________________________________________________
Has the client previously received any mental health services?
If yes, please list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Approved 04/27/2015
http://www.gway.org/
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Family Counseling Intake Form
Child/Adolescent
Client #____________
Are you aware of any complications with client’s pregnancy and
birth? If yes, please describe
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
When did client achieve the following developmental
milestones?
Milestone Age
Sitting up
Turning over
Talking
Crawling
Walking
Potty trained
Who is the client’s primary doctor/pediatrician?
__________________________________________________________________________________________________________________
Does the client have any current medical conditions? If yes,
please list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Does the client have any allergies? If yes, please list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Has the client ever been hospitalized overnight for medical
reasons? If yes, please list
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Past and Current medications
Name Dosage Frequency Prescription
Over the counter
Prescribing
doctor
Reason for taking
Approved 04/27/2015
http://www.gway.org/
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Family Counseling Intake Form
Child/Adolescent
Client #____________
School History
Current School
Name:
Present
Grade:
School
Address:
Teacher
Name:
School Phone:
School
Fax
School
Nurse:
Schools Attended
Kindergarten Seventh GradeFirst Grade Eighth Grade
Second Grade Ninth Grade
Third Grade Tenth Grade
Fourth Grade Eleventh Grade
Fifth Grade Twelfth Grade
Sixth Grade Other
Has the client ever received special education services? If yes,
Please explain:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________Describe
the client’s grades throughout school career
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Describe the client’s conduct throughout school career
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Describe the client’s school attendance
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Has the client ever been suspended or expelled? If yes, please
explain
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Approved 04/27/2015
http://www.gway.org/
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Family Counseling Intake Form
Child/Adolescent
Client #____________
Substance Abuse History
These questions are for the client; however, please let your
therapist know privately if you would
answer yes to the last question.
Do you use Alcohol? How often/much
_________________________________________________________________________________________________________
Do you use tobacco? What type? How often/much?
_________________________________________________________________________________________________________
Have you ever used illegal substances? What type? How
often/much?_________________________________________________________________________________________________________
Have you ever received substance abuse treatment? If yes, please
explain
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Do you consider your substance use to be a problem? If yes,
please explain
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Approved 04/27/2015
http://www.gway.org/
