Counseling Client Intake Form

Date:

Child's Name:

Date of Birth:

School:

Grade:

The purpose of the questionnaire is to help us obtain information about your child and family to aid us in providing the best health care possible. Please answer all questions as they apply to your child. If a question does not apply or you prefer not to answer, leave it blank. If you do not understand a question, please please write don't understand so we can explain it further. This questionnaire will become part of your child’s health record, and as such will be strictly confidential.

Filled Out By:

Relationship to Child:

Are both parents aware that the child is seeking counseling?

Yes No

Is your child currently under the care of a doctor?

Yes No

Doctor's Name:

Contact Information

Does your child have any medical issues or diagnosis that we should be aware of?

Yes No

Is your child currently taking any medications?

Yes No

Name of medication

Dose

Reason for Rx

Is your child supported by an IEP or 504 plan?

Yes No

If so, what is the IEP or 504 for?

Current accommodations?

What are some of your child’s strengths, likes and dislikes?

What are some current stressors in your child’s life?

What are your concerns for your child?

What would you like to see for your child as a result of counseling?

Has your child previously seen a counselor?

Yes No

Describe any treatment your child has tried for this problem or other problems.

What else would you like to share about your child?

Parental Consent to Treat a Minor

give my permission for my child

DOB

to be treated by Amelia P. Lincoln, MEd, MCMHC, in counseling. I also understand that in order to be successful with any individual, their confidentiality needs to be respected, even in the case of a minor child, with the exceptions of if the child is a danger to himself/herself or to others. I understand that this permission to treat with respect for my child’s confidentiality is given with my full consent. This consent will be valid throughout the duration of therapy.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Parent or Guardian's Signature:

Relationship to Minor

Today's Date

Address of Parent or Guardian

City

State

Zip

Other Parent or Guardian's Signature:

Relationship to Minor

Today's Date

Address of Other Parent or Guardian

City

State

Zip

Your information will be encrypted.