Child/Teen Intake Questionnaire

Center for Family Development

Telephone 616 392-7695

Personal Information

Name

Date

Parent/Legal Guardian (if under 18):

Address

City

State

Zip Code

Home/Cell Phone

School

Grade

Special Ed.

Yes No

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

DOB

Age

Gender

Parent

Parent's Cell

Parent

Parent's Cell

Sibling Name

Age

Sibling Name

Age

Sibling Name

Age

Sibling Name

Age

Sibling Name

Age

Name of Primary Care Physician

PCP Phone

Person to contact in case of emergency

Relationship to you

Phone

Referred By (if any)

History

Previous therapist/practitioner

If yes, please list:

If yes, please list and provide dates:

General and Mental Health Information

1. How would you rate child's current physical health?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems you are currently experiencing:

2. How would you rate their current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems child is currently experiencing:

4. Please list any difficulties child experiences with their appetite or eating problems:

If yes, for approximately how long?

If yes, when did they begin experiencing this?

If yes, please describe:

Share about any developmental delays regarding motor skills, language, social and emotional development.

If yes, please describe.

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

Daily Weekly Monthly Infrequently Never

If yes, for how long?

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

How does the child relate to other family members?

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

Is there anything significant that has happened within the family that is important for us to be aware? Such as relationship conflicts, deaths, etc.

Additional Information

If parents are divorced, who has custody?

Does your child enjoy school? Is there anything stressful about his/her current school experience?

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

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

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

Insurance Information

Primary Insurance Company

Policy Number

Group #

Employer Name

Name of Policyholder

Policyholder Birth Date

Address

City

State

Zip Code

Telephone

Secondary Insurance Company

Policy Number

Group #

Employer Name

Name of Policyholder

Policyholder Birth Date

Address

City

State

Zip Code

Telephone

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