Patient Intake Form (Child)

Boston Psychiatric Alliance - Dr. Jan Urkevic

Boston Psychiatric Alliance

(617) 291-6443

Client Information

First name

Last name

Date of birth

Gender

Parent or Guardian Information

First name

Last name

Phone number

Email address

Relationship to child

Address

Can we contact you by phone, email, and voicemail?

Yes No

If no, what is your preferred method of communication?

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this person?

Yes No

Medical History

Has the child previously received therapy?

Yes No

If yes, what is the therapist's name?

Has the child previously been prescribed psychiatric medication?

Yes No

If yes, what medications are they currently taking?

Does the child have any pre-existing medical conditions?

Is there anything else regarding the child's medical history that we should be aware of?

Family History

Provide the name of the child's parents and briefly describe their relationship.

Does the child have any siblings?

Yes No

If yes, please provide the names of the child's siblings and briefly describe their relationship.

Personal History

Is the child currently attending school?

Yes No

If yes, what grade or level?

Does the child have trouble sleeping?

Regularly Occasionally Never

Does the child exercise?

Regularly Occasionally Never

Does the child have a healthy and balanced diet?

Regularly Occasionally Never

Does the child do chores or tasks around the house?

Regularly Occasionally Never

How often is the child on the internet?

Regularly Occasionally Never

How often does the child play video games?

Regularly Occasionally Never

How often does the child interact with their friends?

Regularly Occasionally Never

How often does the child have time for fun and recreational activities?

Regularly Occasionally Never

Is there anything else regarding the child's personal history that we should be aware of?

Reasons for Visit

Describe the reasons for seeking therapy.

Describe any goals or outcomes you hope the child to achieve from therapy.

Describe any significant life changes or stressful events that the child has recently experienced.

Is there anything else you'd like to tell us about?

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