Child Intake

Insurance ID number

If other insurance, please list:

Policy Holders Name and Birthdate

Secondary Insurance

Secondary insurance ID number

Childs First, Middle, Last name

Child's Birth date

Race

Age

Gender

Phone number

Address and city

Zip Code

Is your child your:

Birth Child Adopted Child Foster Child

Parents names include step-parents if applicable

Does your child live with both parents?

Yes No

If no, please provide address for the other parent

Phone number of parent

Do both parents share legal and physical custody?

Yes No

If no, please explain the legal agreement on custody

Do both parents that have legal custody agree on child receiving therapy

Yes No

Can we leave you a message

Yes No

Do you want text reminders

Yes No

Email address

Please note: Email correspondence is not considered to be a confidential medium of communication. WE do have HIPPA compliant emails at Northwest Counseling.

Can we email you, including statements?

Yes No

Can we text invoices to you?

Yes No

Parent's Place of Occupation

Place of employment phone number

If needed, is it OK to call your work?

Yes No

Emergency Contact

Emergency contact phone number

Date of first appointment

Have you previously recieved any type of mental health services

Yes No

If yes, which of the following?

Psychotherapy

Medication

Outpatient hospitalization

Inpatient hospitalization

If yes, please provde Name of Provider of facility

Dates of treatment

Location

Reason for treatment

Please describe what brings you in today:

When did symptoms first start for your child? Within the last:

30 days 6-12 months 2 years During adolescence During childhood

What areas of childs life have been impacted by your symptoms?

Work School Home Self-Care Relationships

What would you like to accomplish in therapy?

Current school and grade in school

Is your child on an IEP or 504 plan?

Yes No

If yes, please explain

Please describe academic or other problems your child has had in school

What significant life changes or stressful events have they experienced recently?

Has your child experienced any of the following

Moved

Changed schools

Serious injury/illness in family

Death

Sibling leaving home

Change in parent job

If yes, please list the year and child's reaction

List family members currently living in the same household as the child along with age and any concers with relationships

Please list each family member that is diagnosed with the above conditions

Has your child been diagnosed with any mental health conditions? Please list:

Please list any medications and dosage

Do you consider yourself to be spiritual or religious? If yes, please describe your faith or belief:

Do you celebrate traditional holidays and birthdays?

Yes No

What do you consider to be some of your childs strengths?

What do you consider to be some of your childs weakness?

Mother used during pregnancy

None

alcohol

drugs

cigarettes

Delivery:

Normal

Breech

Cesarean

Transectional

Full-term

Premature

If premature, number of weeks

Birth weight

Birth length

Labor duration

Problems at birth: (for example: infant given oxygen, blood transfusion, placed in an Incubator, etc)

State approximate age when child did the following: • Understood and followed simple directions _____ • Age reached bowel control: day______ night ____ • Age reached bladder control: day______ night ____ • Did child cry excessively? _____ Rarely cried _____ Walked alone _____ Said first word _____ Used 2-word phrases _____ Rolls over_____ Crawls_____ Runs______ Throws ball_______ Sits without support_______ Rides tricycle_______ Fine motor and gross motor coordination_______ Speaks several words______ Names several objects______ Puts 3 words together _________ Smiles______ Shy with strangers________ Separates from parent _________ Cooperative play with others ______

Please specify if any of the milestones were not met on time

List any occupational services child has received:

List any speech services child has received:

Has your child sought information regarding sex from you

Yes No

If yes, what information and how was this handled?

Has this child behaved or spoken in a way that has not been sexually appropriate for a child his or her age?

Yes No

If yes, please describe:

Are you concerned about your child’s sexual behaviors?

Yes No

Please describe

Did mom have any mental health concerns following delivery? Please list

Primary care of child the first year

Care after the first year

Was the child separated from parents? Please list why, age and length of time

In the first two years, did your child experience

Separation from mother

Out of home care

Disruption in bonding

Depression of mother

Abuse

Neglect

Chronic pain

Chronic Illness

Parental Stress

Child's primary physician

Aprox date of last exam

How is your child disciplined? Please list each method and frequency of use:

Vision problems?

Yes No

Hearing problems?

Yes No

Dental problems?

Yes No

Any head injuries or loss of consciousness?

Yes No

Child’s history of serious illness, injury, handicaps, or hospitalization?

If yes, please list where (clinic) it is on file

Any previous testing (school/psychological)?

Yes No

With whom, where and when?

Do you think your child’s use of chemicals is a problem?

Yes No

Type

Alcohol

Marijuana

Other drugs

Comments:

Chemical use for either parent (now and/or past):

Yes No

Which parent?

Type:

Alcohol

Marijuana

Other drugs

Has child witnessed domestic violence?

Yes No

Please explain

Has child experienced divorce?

Yes No

What age were they? How did they handle it? How are they doing now?

Has your child been verbally abused?

Yes No

Has your child been physically abused?

Yes No

Has your child been sexually abused?

Yes No

Please describe any major losses or traumas your child has experienced:

Anything else you would like to share that was not asked on this form?

Please complete the following if your child is within the ages of 6-17. All questions should be answered for symptoms seen within the past 2 weeks Scale is 0 (none, not at all) 1 (Slight, rare less than a day or two) 2 (Mild, Several days) 3 (Moderate, More than half the days) 4 (Severe, nearly every day)
Copyright © 2013 American Psychiatric Association. All Rights Reserved. This material can be reproduced without permission by researchers and by clinicians for use with their patients.

Severity Measures for Children Ages 11-17 Please have child complete. All answers should be symptoms experienced within the past 7 days.

Feeling down, depressed, irritable, or hopeless?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Little interest or pleasure in doing things?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Trouble falling asleep, staying asleep, or sleeping too much?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Poor appetite, weight loss, or overeating?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Feeling tired, or having little energy?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Feeling bad about yourself—or feeling that you are a failure, or that you have let yourself or your family down?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Trouble concentrating on things like school work, reading, or watching TV?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Moving or speaking so slowly that other people could have noticed? Or the opposite—being so fidgety or restless that you were moving around a lot more than usual?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Thoughts that you would be better off dead, or of hurting yourself in some way?

0 (Not at all) 1 (Several days) 2 (More than half the days) 3 (Nearly every day)

Felt moments of sudden terror, fear, or fright