Connect Psych Network, Intake Form (Child)

Before filling out this intake form, Please Read This:

This intake form is not for emergencies or crisis situations. If you are experiencing a mental health emergency, please seek immediate help by calling:

Suicide Prevention Lifeline 1-800-273-8255 911
Suicide & Crisis Lifeline: 988
91

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

Zip Code

City

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 psychiatric treatment?

Yes No

If yes, please provide the name of the psychiatrist or therapist who treated the child.

Has the child ever been prescribed psychiatric medication?

Yes No

If yes, please list any psychiatric medications the child is currently taking, including dosage if known.

Has your child been diagnosed with any psychiatric or mental health conditions?

(Examples: ADHD, anxiety, depression, autism, OCD.)

Does your child have any pre-existing medical conditions or significant health issues?

(Examples: asthma, diabetes, epilepsy, heart conditions, allergies, or other chronic illnesses.)

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

Family and Social History

What is your child’s current living situation?

(Lives with both parents, one parent, relatives, foster care, etc.)

Does the child have any siblings?

Yes No

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

Are there any challenges in the family dynamic or social environment that may impact your child’s mental health?

Does your child have a family history of psychiatric conditions, substance use, or neurological disorders?

(If yes, please specify.)

Personal History

Is the child currently attending school?

Yes No

If yes, what grade or level?

Does your child experience trouble sleeping?

Regularly Occasionally Never

How often does your child engage in physical activity?

Regularly Occasionally Never

Does the child have a healthy and balanced diet?

Regularly Occasionally Never

How often does your child have screen time (Internet, video games, etc.)?

Regularly Occasionally Never

How often does the child interact with their friends?

Regularly Occasionally Never

How often does your child participate in recreational activities (hobbies, sports, creative arts)?

Regularly Occasionally Never

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

Reasons for Visit

What concerns or symptoms have prompted you to seek psychiatric evaluation for your child?

(Examples: mood changes, difficulty focusing, behavioral issues, sleep problems, anxiety, etc.)

What goals or outcomes do you hope to achieve through this evaluation or treatment?

(Examples: diagnosis clarification, medication management, symptom relief, etc.)

Has your child experienced any significant life changes or stressful events recently?

(Examples: family separation, loss of a loved one, bullying, moving, etc.)

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

Your information will be encrypted.