Intake Form (Child/Adolescent)

Emergency Assistance

If this is an emergency, call:

Crisis Line: 988 (call or text 24/7)
911

Client Information

First name

Last name

Affirmed/Preferred name

Date of birth

Current age

Primary Address

Secondary Address

Client Phone Number (If different from Parent/Guardian)

Consent for Contact

Phone/Voicemail

Text

Pronouns

Sex at Birth

Gender

Sexual Orientation (if known)

Relationship Status (if applicable)

Ethnicity

Cultural Background

Faith Orientation/Spirituality Information

Parent and/or Guardian Information

Add Parent/Guardian

Emergency Contact Information

Add another emergency contact

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:

What medications is the child taking (if any) and for what conditions? Include the dosage and amounts.

Does the child have any allergies? Please list all allergies, reactions, and severity of reactions to each allergen.

Educational Information

Current Grade

Learning Barriers (if any)

Legal History

Open Legal Cases?

Yes No

Previous Arrests?

Yes No

Previous Arrests?

Yes No

If yes, please elaborate:

Has there been DCF or Related Agency Involvement?

Yes No

If yes, please elaborate:

Mental Health Information

Reason for Seeking Counseling (without much detail or reportable information):

What are your (client's) goals for counseling?

What are your (client's) major stress areas?

What are your (client's) strengths?

Have you ever received counseling before?

Yes No

If yes, when and regarding what challenges?

Any previous mental health diagnoses?

Have you ever been prescribed medication for psychiatric or emotional challenges?

Yes No

If yes, please specify the name and dosage of each medication:

Please provide information on any psychiatric or mental health inpatient admission, including year and location.

Do you drink alcohol?

Yes No

If yes, specify the number of alcoholic drinks per week:

Do you smoke or vape?

Yes No

If yes, please specify whether you smoke or vape and how often:

Do you use recreational drugs?

Yes No

If yes, please specify the type and frequency:

Do you have thoughts of harming/injuring yourself?

Yes No

Do you have thoughts of killing yourself?

Yes No

Have you ever attempted to die by suicide?

Yes No

Do you have thoughts of hurting/killing others?

Yes No

Have you ever injured yourself on purpose?

Pulling Out Hair Skin Picking Burning Your Skin Cutting Your Skin Scratching Your Skin Multiple Methods No Other

If anything other than no, please specify the method(s) of self harm and last occurrence of any self harm:

Is there a history of mental illness in your family?

Yes No

If yes, please elaborate:

What else would you like me to know?

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