Adolescent Individual Intake Questionnaire

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Personal History

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.

School and Social Functioning

More About You

Symptoms

Psychiatric History

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

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Family History

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