Date
MM
DD
YYYY
Child's Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Age
Person(s) completing this form?
Name
Age
Primary Phone Number
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Email Address
Name
Age
Primary Phone Number
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Email Address
Parents are currently:
Married
Divorced
Remarried
Never married
Other
If other, please explain.
Are there any legal custody arrangements between the patient's parents/legal guardians?
Yes
No
Name
First Name
Last Name
Age
Primary Phone Number
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Email Address
Is your child/teen adopted?
Yes
No
If so, at what age?
What is known about the child's biological parents?
Who else lives in the child's home? (Please include names and ages of siblings)
Religious denomination/affiliation? (specify, if applicable)
If involved in religion, how much so?
Active
Some/Irregular
None
Ethnicity/National Origin
Other Important Identifiers
How did you hear about us?
Insurance
Friend/Family
Web/Social Media
Newspaper
Other
If other, please explain.
Phone Number
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
May I contact your child's medical doctor so that they can be fully informed? Can we coordinate treatment?
Name of Primary Insurance Company
Primary Subscriber's Name
First Name
Last Name
Primary Subscriber's Date of Birth
MM
DD
YYYY
Primary Subscriber's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Member ID Number
Group Number (if applicable)
Name of Secondary Insurance Company
Primary Subscriber's Name
First Name
Last Name
Primary Subscriber's Date of Birth
MM
DD
YYYY
Primary Subscriber's Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Member ID Number
Group Number (if applicable)
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
(###)
###
####
Relationship to you?
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Please describe the main difficulty that has brought your family to see me. How long has it persisted?
Please describe any changes or incidents (such as moving, death in the family, change of schools, birth of sibling) which seemed to have affected the child.
What was the child’s reaction to the above changes or incidents?
Have you tried to resolve the problem? Please list the things that have and have not worked.
How distressing is this issue for your child (on a scale of 1-10, with 1=not distressing, 10=most distressing):
1
2
3
4
5
6
7
8
9
10
How has this affected the child's ability to function in daily life?
Not at all
Minimally
Moderately
Significantly/Severely
How has this affected the child's ability to function academically?
Not at all
Minimally
Moderately
Significantly/Severely
How has this affected the child's ability to function within the family?
Not at all
Minimally
Moderately
Significantly/Severely
How has this affected the child's ability to function interpersonally/socially?
Not at all
Minimally
Moderately
Significantly/Severely
Symptoms and issues you have observed (please check all that apply)
Energy Levels
Normal
Too much
Too little
Sleep Problems
None
Trouble Falling Asleep
Trouble Staying Asleep
Trouble Sleeping Too Much
Trouble Sleeping Too Little
Eating Habits (if applicable)
Weight Changes (if applicable)
If you checked off a weight change, please describe.
Behavior Problems
Has your child ever received psychological, psychiatric, drug or alcohol treatment, or counseling services before?
If you answered yes, please indicate: When? From whom? For what? With what results?
What medication(s) is your child currently taking? If applicable, please indicate the medication, the dosage, and the prescribing physician.
What medication(s) has your child taken in the past?
Has your child ever received psychological testing? If so, whom may I contact for a copy of the report?
Prenatal Medical Illnesses and Health Care
Length of pregnancy?
Birthweight?
Any birth complications or problems?
Feeding and Sleep Patterns (or problems?)
Personality/Temperament
Crawled?
Walked without holding on?
Spoke first word?
Toilet trained?
Any speech, hearing, language or motor difficulties?
List all childhood illnesses, hospitalizations, medications, allergies, important accidents and injuries, surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions. Condition? Age? Treated by whom? Results?
Is there a family history of any medical or mental health problems? Please describe.
Has the child been exposed to traumatic events (the loss of a loved one, a natural disaster, etc.) or been subject to abuse or neglect (physical, verbal, sexual, or emotional)? Please describe.
Has the child moved multiple times? How did they respond?
Please list the names and dates of any institutional placements or foster care (if applicable)
School Name / Dates Attended / Academic Performance / Problem Areas?
May I call and discuss your child with the current teacher?
If so, what is the teacher's name and phone number?
Does your child have an Individualized Education Plan (IEP) for special education purposes? If so, whom may I contact to obtain a copy?
Please describe any learning problems.
Has your child ever repeated a grade?
List hobbies, sports, recreational, musical, TV, and toy preferences, etc.
What do you see as being your child's strengths and weaknesses?
Please briefly characterize how your child gets along with: Parents?
Please briefly characterize how your child gets along with: Siblings?
Please briefly characterize how your child gets along with: Peers?
Please briefly characterize how your child gets along with other important relationships (extended family, nanny, boyfriend/girlfriend, etc.)
Are there any stressful events occurring in the family that could be affecting the child?
What do you do together as a family?
How does your family express feelings?
How often are there conflicts in your family?
What are the conflicts typically about?
How are these conflicts resolved?
Who is typically in charge of discipline in your family?
What type of discipline is used in your family?
Is there anything else I should know about that does not appear on this form and that might be important?
We would be interested in your feedback regarding this intake form. If you have any feedback, please put your comments below!
