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