Therapy Intake Form (Child)

Emergency Assistance

If this is an emergency, call:

Crisis Line: (256) 716-1000
911

IDENTIFYING INFORMATION - CHILD

Child's First name

Middle Initial

Child's Last name

Date of birth

Age

Grade

Gender

Race/Ethnicity

Religious Affiliation

Person Completing This Form

Today's Date

Contact Information

Child's custodian/guardian(s) is/are

Phone number

Email address

Other Phone number

Other Email address

Child's Home Address

Please upload an image of caregiver's Photo ID (eg: Driver's License):

PHOTO ID:

Add file

Please upload a file

Is your child driving?

Yes No

Will your teen ever drive themselves to an appointment?

Yes No

If child will be driving themselves, please upload an image of Photo ID (eg: Driver's License):

Teen's PHOTO ID

Add file

Please upload a file

Teen's Phone number

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

Yes No

If no, what is your preferred method of communication?

Can we contact your teen by phone, email, and voicemail?

Yes No

Special Instructions

Parent / Guardian Information:

Add Another Parent/Guardian's Information

Emergency Contact

Add another emergency contact

In case of an emergency, do we have permissions to contact this/these person(s)?

Yes No

Insurance Information

Will you be using insurance?

Yes No

Name of Primary Insured

Their DOB

Pre-Authorization Required?

Yes No

Authorization Number:

Insurance Company

Policy ID

Group Number

Please upload images of the front and back of your Insurance Card(s):

FRONT

Add file

Please upload a file

BACK

Add file

Please upload a file

Do you have a Secondary Policy?

Yes No

Name of Secondary Insured

Their DOB

Secondary Insurance Pre-Authorization Required?

Yes No

Secondary Insurance Company

Secondary Policy ID

Secondary Group Number

If you have a Secondary Policy please upload images of the front and back of your Insurance Card(s):

Secondary FRONT

Add file

Please upload a file

Secondary BACK

Add file

Please upload a file

REASON FOR SEEKING TREATMENT:

Please briefly describe the problems your child is experiencing

What has happened to cause you to seek help NOW?

What do you hope to be able to do or achieve as a result of treatment?

What do you consider to be other stresses in your child's life?

HISTORY OF THE PROBLEM

When did your child first start experiencing the problem(s) that brought you in today?

How often does the problem occur?

How long does it last?

Does your child have any thoughts of harming him/herself?

No Yes Don't Know

If yes, please explain

Has your child ever attempted to harm him/herself?

No Yes

If yes, please explain

Does your child have any thoughts of harming someone else?

No Yes Don't Know

If yes, please explain

Has your child ever attempted to harm someone else?

No Yes

If yes, please explain

Has your child previously received therapy/counseling of any kind?

Yes No

If yes, where did your chiild receive care and for how long?

What concerns were addressed in therapy?

Was this experience helpful? (please explain)

Has your child ever been hospitalized for emotional/behavioral problems?

No Yes

If yes, when/where as this?

Has your child ever been prescribed medication to control emotional/behavioral problems?

No Yes

If yes, please list medications, when prescribed and by whom:

To your knowledge, has your child experimented with alcohol/drugs?

No Yes Don't Know

Are you concerned that your child might have or be developing a problem with alcohol or drugs?

No Yes

If yes, please explain:

FAMILY HISTORY

Has this child ever experienced any parental separations, divorces, or death?

No Yes

If yes, when

How old was the child at the time?

Please describe the circumstances

If parents are separated or divorced, who has custody of this child?

How often does the other parent see this child?

Weekly+ Once or twice a month Few times a year Never

Please list the age and sex for each sibling (including those deceased, and step-siblings):

Add next sibling

Other than any children already indicated above and parents, who else lives in the child's household?

Has anyone in the child's family had treatment for emotional problems?

No Yes

If yes, please briefly explain (who/when):

Has anyone in your family ever attempted or committed suicide?

No Yes

If yes, please briefly explain (who/when):

Family Health / Medical History

How is father's health at present?

Poor Unsatisfactory Satisfactory Good Very Good

How is mother's health at present?

Poor Unsatisfactory Satisfactory Good Very Good

Please list any persistent physical symptoms or health concerns (eg: chronic pain, headaches, hypertension, diabetes, etc.):

Has anyone in your child's family (either immediate family members or relatives) experienced difficulties with any of the following? (check any that apply and list family member: eg: sibling, parent, uncle, etc)

For each condition chosen above select the condition and list the family member(s) effected:

Add another family member affected by a condition listed above

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

What kinds of stressful events has your child experienced recently?

What kinds of stressful events have family members experienced recently?

CHILD'S EDUCATION

School name

Grade

Age

Teacher Name

Approximate Grades

Does your child receive any special education services?

Yes No

If Yes, describe difficulties addressed and services provided:

Describe any difficulties or problems your child is having in school:

CHILD'S DEVELOPMENT

Pregnancy and delivery:

Was this a planned pregnancy?

No Yes

Was the mother under a doctor's care?

No Yes

Number of previous pregnancies / miscarriages

Describe any complications that occurred during the pregnancy:

What drugs/medications were used during the pregnancy?

At this child's birth what were:

Mother's age?

Father's age?

Length of Pregnancy in weeks:

Birth Weight

lbs

Length of labor in hours

Child's condition at birth:

Mother's condition at birth

Length of stay in hospital:

Mother Days

Child Days

Is this child adopted?

No Yes

If yes, please provide adoption history:

Was this child:

Breast Fed? Bottle Fed?

If breast fed, when was she/he weaned?

At what age was this child toilet trained?

Days?

Nights?

Did bed-wetting occur after toilet training?

No Yes

If yes, until what age?

Did soiling occur after toilet training?

No Yes

If yes, until what age?

Describe sleep patterns or problems:

Language difficulties?

No Yes

If yes, describe:

Delays with child's walking?

No Yes

If yes, describe:

As a young child, did your child have problems getting along with others?

No Yes

If yes, describe:

Were there other problems experienced during the child's first year?

No Yes

If yes, describe:

CHILD'S MEDICAL CARE

Child's physician

Physician's telephone:

Physician Address

How often does this child see a doctor?

Date of last visit?

Is this child currently on any medication?

No Yes

If yes, indicate type and reason:

Please list below details of any conditions you checked above, including any additional childhood illnesses and other medical conditions:

Add new row

CHILD'S INTERESTS AND ACTIVITIES

Is this child involved in any extracurricular activities, such as school sports or music programs, clubs or religious organizations?

No Yes

If yes, please describe

Please describe your chiild's strengths and positive characteristics?

Other information you feel is important and wasn't asked about:

Your information will be encrypted.

Therapy Intake Form (Child)

Emergency Assistance

IDENTIFYING INFORMATION - CHILD

Contact Information

Parent / Guardian Information:

Emergency Contact

Insurance Information

REASON FOR SEEKING TREATMENT:

HISTORY OF THE PROBLEM

FAMILY HISTORY

Family Health / Medical History

Has anyone in your child's family (either immediate family members or relatives) experienced difficulties with any of the following? (check any that apply and list family member: eg: sibling, parent, uncle, etc)

CHILD'S EDUCATION

CHILD'S DEVELOPMENT

Pregnancy and delivery:

CHILD'S MEDICAL CARE

CHILD'S INTERESTS AND ACTIVITIES

Emergency Assistance

N. Gail Seemann, LPC

Licensed Professional Counselor, Lifestream Family Counseling