Client Intake Form (Child, under 18)

Personal Information

Name

Date

Address

DOB

Race

Age

Gender

Home Phone

Cell/Work/Other Phone

O.K. to email?

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Education Completed

Referred By (if any)

May we thank this referral?

Parent or Guardian Information

First Name:

Last Name:

Long text

Home phone

Cell phone

Medical History

Has the child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for the visit.

Date of last physical exam

Please list the medications the child is taking and for what conditions. Include the dosage and amounts.

Does the child have any allergies to medications?

Previous therapist/practitioner

If yes, please list:

If yes, please list and provide dates:

General Health Information

1. How would you rate your current physical health?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing:

2. How would you rate your current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems you are currently experiencing:

3. How many times per week do you generally exercise?

What types of exercise do you participate in?

4. Please list any difficulties you experience with your appetite or eating problems:

If yes, for approximately how long?

If yes, when did you begin experiencing this?

If yes, please describe:

9. How often do you engage in recreation drug use?

Daily Weekly Monthly Infrequently Never

If yes, for how long?

11. What significant life changes or stressful events have you experienced lately?

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you (e.g. father, grandmother, uncle, etc.)

Family Member

Additional Information

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?

Emergency Contact Information

First Name

Last Name

Home phone number

Cell phone number

Relationship to child

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