Adolescent Individual Intake Questionnaire

Child's Name

Date Of Birth

Personal History

What is the reason you are coming in for counseling? Is there something specific, such as a particular event? If this is due to a specific event, when did it start or happen? How is your life affected by this issue? Please be as detailed as you can.

What do you think you need the most help with right now?

Please rank your concerns in the following areas on a scale of 1 to 10 (0 = No problems and 10 = Major problems). You may use the same number for more than one area.

Depression

Anxiety/Worry

Parents

Sex

School

Substance Use

Legal

Anger Issues

Suicidal Thoughts

Trouble eating food

School and Social Functioning

Are you currently in school? If so, what grade are you in?

When did/do you attend class?

If you are attending, what is school like for you?

If attending, what school do you go to?

What was your grade point average last report card?

Are these grades better or worse than usual?

Have you ever attended any special classes (i.e., resource program, gifted programs)?

Do you have a learning disability? If so, what is the disability?

Yes No

During the past school year, about how many days were you absent when you were supposed to be in school?

Have you ever been suspended or expelled from school? If yes, please share additional details.

Have you ever been in trouble at school related to an alcohol or other drug problem? If yes, please share additional details.

More About You

What do you like to do for fun or enjoyment? Do you have any hobbies that you enjoy regularly? Do you prefer your enjoyment alone, with others, or both?

Are you sexually active?

Yes No

Do you practice safe sex?

Yes No

Do you currently drink alcohol? If so, describe the type, amount, and how often (daily, weekly, monthly, etc.).

Yes No

Do you smoke cigarettes or use any nicotine products? If so, what and how often?

Yes No, I don't use any nicotine products.

Do you currently use recreational drugs? If so, describe type, amount, frequency

Yes No

Has your drinking or drug use ever caused problems in your family, relationships, or job?

Have you ever been arrested for a D.U.I or other drug related offense? If yes, please give dates and details.

Yes No

Is it difficult for you to stop or control the amount you drink or use?

Yes No N/A

If you feel you have a problem with alcohol or drugs, would you like help?

Symptoms

Psychiatric History

Have you seen a mental health professional before? If so, please specify dates, the reason for counseling, and your experience. What was your diagnosis, if any?

Yes No

If applicable, list all psychotropic medications you are currently taking, for how long, and for what reason. What is the dosage of each? What time of day do you take it (morning, evening, bedtime)? Does it help?

If taking prescription medication, who is your prescribing doctor? Please include type of doctor, name, and phone number.

Do you have, or have you ever had, suicidal thoughts?

If yes, when? If yes, how would you end your life? No, I have never had suicidal thoughts.

Have you ever attempted suicide? Please list all attempts and your age when each happened, starting from the most recent event to the oldest event.

If yes, when? If yes, how did you do it? No, I have never attempted suicide.

Have you ever been hospitalized for a psychiatric issue? If yes, please describe why, when, and the length of your stay.

Yes No, I have never been hospitalized for a psychiatric reason

Do any family members struggle with the following challenges? Please specify which family member.

Add Additional Family Member

Family History

Please describe your relationship with your mother

Please describe your relationship with your father

Do you have siblings?

Yes No

If so, please describe your relationship with them.

If you are in a relationship, please describe the nature of the relationship and months or years together.

Who do you know that you would consider your closest sources of support or your "inner circle" (e.g., grandparent, aunt, uncle, friend, cousin, teacher, etc.)?

What else would you like me to know?

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