Therapy Intake for (Minor)

National Suicide Prevention Lifeline

If this is an emergency, call:

Crisis Line: 800-273-8255
911

Child or Adolescent 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

Second Parent or Guardian Information

First Name

Last name

Phone number

Email address

Relationship to child

Address

If TRICARE, please provide the SSN of the Military Member

If you have IEHP Please provide Insurance number

Personal History

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

Presenting Problem

What concerns do you have about your child?

What makes you seek help at this time?

How long have these concerns been present?

How severe are these concerns today?

What do you think might be causing these concerns?

What has helped with these concerns, if anything?

What changes would you like to see with your child and/or family?

Developmental History

Please describe the circumstances surrounding your pregnancy with this child. Was the pregnancy planned or unplanned, wanted or unwanted? How supported did you feel by family and friends during your pregnancy and during the first year of your child's life?

Please describe any difficulties your child experienced while in utero and during birth (like pregnancy complications, exposure to substances, or prematurity).

Please describe any developmental concerns you had about your child during the first three years of life (like difficulty meeting developmental milestones or concerning differences when compared to children of a similar age).

Medical History

When was your child's las well child check? What concerns were identified during the most recent visit?

Does your child have any current or recent medical problems?

What medications does your child currently take?

Mental Health History

Does anyone related to this child experience mental health challenges in the past or currently (including undiagnosed problems and substance abuse)?

Has your child ever received a mental health diagnosis?

Has your child ever received assessment or treatment for mental health concerns (like outpatient counseling, medication, hospitalization, residential treatment?

Does your child engage in any behavior that you consider risky (like using drugs, running away, sexually inappropriate behavior, involvement with the law?

Has your child ever tried to hurt themselves, talked about suicide, or attempted suicide?

Family Situation

Please describe who lives in your child's immediate household(s). If your child lives in more than one home, please include information about members of each home (parents, stepparents, siblings, stepsiblings, etc.)

How does your child get along with members of the household? Who is your child close with? Who does your child experience conflict with?

What significant family events has your child experienced (like the recent birth of a sibling, divorce, loss of a loved one, separation from family members, geographic moves, etc.)?

Trauma History

Has your child been in a serious natural disaster like a flood, tornado, hurricane, earthquake, or fire?

Yes No

Serious accident or injury like a car/bike crash, dog bite, or sports injury?

Yes No

Threatened, hit or hurt badly within the family?

Yes No

Threatened, hit or hurt badly in school or the community?

Yes No

Attacked, stabbed, shot at or robbed by threat?

Yes No

Someone doing sexual things with the child when they couldn't say no or when the child was forced or pressured?

Yes No

Seeing someone in the family threatened, hit or hurt badly?

Yes No

Someone asking or pressuring the child to do something sexual online like take or send pictures?

Yes No

Someone bullying the child in person or online, including saying very mean things that scare him/her?

Yes No

Someone close to the child dying suddenly or violently?

Yes No

Please provide additional information about any of your YES responses below.

Schooling

Where does your child attend school? What grade is your child in?

Has your child been evaluated due to academic concerns? If so, what was the outcome of the assessment?

What is your child's typical school performance?

What is your child's typical behavior at school?

Please describe any concerns you have about your child's schooling?

Friends and Extracurricular Activities

How well does your child get along with peers? How easily does your child make friends?

What extracurricular activities, outside of school, does your child participate in?

Please describe any concerns you have about your child's interactions with peers or participation in activities outside of school.

Short text

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Therapy Intake for (Minor)

National Suicide Prevention Lifeline

Child or Adolescent Information

Parent or Guardian Information

Second Parent or Guardian Information

Personal History

Presenting Problem

Developmental History

Medical History

Mental Health History

Family Situation

Trauma History

Schooling

Friends and Extracurricular Activities

National Suicide Prevention Lifeline

Irma Cabral, MA, LMFT