Child and Adolescent Intake Form

Name of Child *

First Name

Last Name

Email Address of parent or legal guardian *

Telephone *

Message *

Address

Grade

School

Teacher

Text 6

People living in same household as child:

Name Age Relationship to Child

Text Area 2

Other significant people NOT livining in the same house hold

Name Age Relationship to Child

Check any areas in which your child/teen is having problems

Weight

Health

Motor Skills

Nervouse Habits

Fire-Setting

Getting Along with Adults

Aggressive Behavior

Diet and Eating

Hygeine

Language Skills

Sexual Acting Out

Suicidal Thoughts

Getting Along with Kids

Delinquent Behavior

Sleeping

Potty-Training

Mood

School

Hurting Animals

Nightmares

Bedwetting

Behavior

Self- Harm

Drug Use

Seperation Anxiety

Other

Briefly explain the items you checked

Are there any other concerns?

What reinforcements do you use with your child?

What discipline is used in the home?

What are some of your child's fears?

Has your child previously been or are they currently in therapy or under the care of a psychiatrist?

Name of Counselor/Psychiatrist

Agency

City

Dates

Phone Number

Has your child been previously hospitialized?

Name of Mediciation Reason of Medication Dosage Prescribing Physician

Name and phone number of primary care physician or pediatrician

When was your child's last physical exam?

Anything else you would like us to know?

Survey

Option One

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree

Option Two

Strongly Disagree

Disagree

Neutral

Agree

Strongly Agree