Child and Adolescent-General Intake

PARENT OR GUARDIAN: PLEASE COMPLETE AND BRING THIS FORM TO CLINIC

Who referred you to our clinic?

DEMOGRAPHICS:

Name of the person completing this form:

Relationship to the child:

Child’s Full Legal Name:

Is there another name the child prefers being called?

Child’s Date of Birth:

Age:

Gender:

Male Female

Race:

Religion:

Is the child adopted?

Yes No

If yes, are they aware?

Yes No

Who lives in the same household as the child?

Name:

Sex:

Male Female

Age:

Relationship to Child:

Add New Individual

Parent(s) occupation:

What are the main concerns that you have about your child?

How long have you had these concerns?

What are your goals for treatment of your child?

Please select all of the following symptoms that apply to your child:

Drastic mood swings

Episodes of decreased need for sleep

Extreme hyperactivity

Racing thoughts

Talking so fast it’s hard to understand

Overly happy or euphoric

Overly confident

Irritability

Severe angry outbursts

If "Severe angry outbursts" is selected, please specify:

Verbal Physical

Worrying too much

Feeling or acting restless

Muscle tension

Panic or anxiety attacks

Fear of looking stupid or being embarrassed

Fear of offending others

Any other fears or phobias

Thoughts, feelings or pictures that come into the child’s mind even if he/she does not want them to?

Habits the child feels they must do even if he/she knows it does not make sense (for example excessive cleaning, checking, repeating, counting, organizing or hoarding things)?

Poor body image

Trying to lose weight even though he/she is not overweight

Intentionally throwing up after eating

Difficulty learning

Trouble understanding social cues

Difficulty forming or keeping friendships

Being very sensitive to sound, light, touch or smell

Tics, twitches or involuntary movements

Making involuntary sounds

Traumatic experiences: Has your child ever been exposed to actual or threatened death, serious injury, or sexual violence?

No Yes

PAST PSYCHIATRIC HISTORY:

Has your child ever seen a psychiatrist or therapist/counselor before?

Yes No

If yes, provide the needed information below:

Name of provider:

Dates seen:

Reason:

Add New Provider

Has your child ever been admitted to a psychiatric hospital?

Yes No

If yes, provide the needed information below:

Name of provider:

Dates seen:

Reason:

Add New Provider

Has your child ever attempted suicide?

Yes No

If yes, please describe:

Does your child engage in any self-harm behaviors (like cutting)?

Yes No

If yes, please describe:

Has your child ever been violent or aggressive?

Yes No

If yes, please describe:

FAMILY HISTORY:

Please select any known psychiatric illnesses in blood relatives of the child:

Does the child have any blood relatives with heart defects or arrhythmias?

No Yes Unknown

Does the child have any blood relatives who died suddenly at a young age?

No Yes Unknown

SUBSTANCE USE HISTORY:

Does the child use:

Alcohol Tobacco Illegal drugs None

If any of the substance above is selected, please specify:

MEDICAL HISTORY:

Any other serious illness or disease?

Has your child ever had surgery?

No Yes

If yes, describe and give dates:

Has your child ever had any serious injuries?

No Yes

If yes, describe and give dates:

Biological females only:

Has your child started menstruation?

No Yes

If yes, at what age:

Are periods regular?

No Yes

Date of last menstrual cycle:

Is there any change in symptom severity with periods?

No Yes

If yes, please describe:

MEDICATIONS:

Please list all medication your child is currently taking:

Name of medication:

Dose of medication:

Who prescribes it?

Add New Medication

If other is selected, please specify:

ALLERGIES:

Please Select One

No Known Drug Allergies Other

Describe 'Other'

Please list any allergies the child has:

SOCIAL HISTORY:

Name of child’s current school:

Current grade:

Did the child repeat any grades?

No Yes

Does the child have a 504 plan or IEP?

No Yes

Is the child in ESE or special needs classes?

No Yes

Has the child ever been suspended or expelled?

No Yes

Does the child get bullied by peers?

No Yes

Has the child ever been the victim of abuse?

No Yes

Has the child been arrested?

No Yes

Are there any weapons or guns in your home?

No Yes

If so, does your child have access to them?

No Yes

DEVELOPMENTAL HISTORY:

(Not all parents remember the answers to these questions. You can write down what you do remember or look back if you kept a baby book.)

What was the length of the pregnancy?

Were any medications or substances used during pregnancy?

No Yes

If yes, what?

Any other complications of pregnancy or delivery?

No Yes

If yes, please specirfy:

How much did the baby weigh at birth?

Did the baby start breathing right away?

No Yes

Were there any problems with the baby after he/she was born?

No Yes

If yes, please specify:

When did the baby leave the hospital?

When the baby came home, were there any problems?

No Yes

If yes, please specify:

When did the baby really smile (not “gas”)?

When was the baby able to sit by him/herself (without help)?

When did the baby walk by him/herself (without holding on)?

When did baby say his/her first word?

When did the baby say short sentences (such as “go bye bye”)?

Did the child have trouble learning to speak?

No Yes

Was he/she different from brother or sister or other children?

Is the child toilet trained?

No Yes

If yes, how old when trained?

How old was the child when he/she was able to:

When did the child learn to ride a tricycle?

When did the child learn to ride a bicycle without training wheels?

When was the child able to get dressed by him/herself?

When was the child able to tie shoelaces?

What hand does the child prefer to use?

Right Left No Preference

At what age did you notice this?

Did anything else significant occur during the child’s development years?

No Yes

If yes, please specify:

TESTING HISTORY:

Did the child ever have IQ or achievement testing?

No Yes

Has the child been tested for hearing abnormalities?

No Yes

Has the child been tested for speech/ language abnormalities?

No Yes

Has the child ever received occupational or physical therapy?

No Yes

If "Illness in Family" is selected, please specify:

if "Other" is selected, please specify:

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