Therapy Intake Form (Child)

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

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

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

Yes No

If no, what is your preferred method of communication?

Personal History

Is the child currently attending school?

Yes No

If yes, what grade or level?

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

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

Reasons for Visit

Describe the reasons for seeking therapy.

Describe any goals or outcomes you hope the child to achieve from therapy.

Describe any significant life changes or stressful events that the child has recently experienced.

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

Your information will be encrypted.

Therapy Intake Form (Child)

Emergency Assistance

Client Information

Parent or Guardian Information

Personal History

Reasons for Visit

Emergency Assistance

Mandarin Counseling