Client Intake Form

The Client is a(n) Please choose between the adult or child intake form

Child Adult

Child Intake Assessment Form

Adult Intake Assessment Form

Identifying Information

Child’s name

Today’s date

Date of birth

Age

Grade

Race/ethnicity

Religious affiliation

Client’s name

Today’s date

Date of birth

Age

Race/ethnicity

Person(s) completing this form

Who suggested that you contact New Roots Counseling?

Child’s custodian/guardian(s) is/are

Were parents ever married?

Yes No

If child’s parents are divorced or separated, who has legal custody?

How often does the non custodial parent see this child?

Weekly or more often Once or twice a month Few times a year Almost never

If parents have joint custody, how is child’s visitation split?

Is there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling?

Yes No

If yes, describe

Child’s Home Address

City

State

Zip Code

Client’s Information

Home Address

City

State

Zip Code

Home Telephone

Other Phone (specify type)

Cell phone

E-Mail

Is it okay to contact you at home?

yes no

**Is it okay to leave a (phone or text) message?

Yes No

Special instructions?

**Your confidentiality cannot be ensured/guaranteed with phone and text messages. You are waiving your HIPPA guaranteed privacy by agreeing “yes” to receive or send text or phone messages. Please do not text the counselor with specific information you would like to keep confidential.

Religious affiliation

Highest Grade or Degree Completed

Emergency Contact Name

Relationship to Child

Address

City

State

Zip Code

Home Telephone

Other Phone (specify type)

Mother’s Information

Mother’s name

Date of birth

Mailing Address

Home Telephone

E-Mail

Race/ethnicity

Religious affiliation

Highest Grade or Degree Completed

Specify

Employment status (Check all that apply)

Employed

Retired

Disabled

Student

Homemaker

Unemployed

Current employer is

Type of work

Years on current job

Business Phone

Is it okay to contact the client’s mother at work?

Yes No

Is it okay to leave a message?

Yes No

Special calling instructions?

Is it okay to contact you at work?

Yes No

**Is it okay to leave a message?

Yes No

Special calling instructions?

Emergency Contact Information

Emergency Contact Name

Relationship to Client

Address

City

State

Zip Code

Home Telephone

Other Phone (specify type)

**Is it okay to leave a (phone or text) message?

yes no

Special calling instructions?

Father’s Information

Father’s name

Date of birth

Mailing Address

Home phone

E-Mail

Race/ethnicity

Religious affiliation

Highest Grade or Degree Completed

Specify

Employment status (Check all that apply)

Employed

Retired

Disabled

Student

Homemaker

Unemployed

Current employer is

Type of work

Years on current job

Business Phone

Is it okay to contact the client’s father at work?

Yes No

Is it okay to leave a message?

Yes No

Special calling instructions?

Step-Parent’s Information

Step-parent’s name

Date of birth

Mailing Address

Home phone

E-Mail

Race/ethnicity

Religious affiliation

Highest Grade or Degree Completed

Specify

Employment status (Check all that apply)

Employed

Retired

Disabled

Student

Homemaker

Unemployed

Current employer is

Type of work

Years on current job

Business Phone

Is it okay to contact the client’s step-parents at work?

Yes No

Is it okay to leave a message?

Yes No

Special calling instructions?

Reason for Seeking Treatment

Please briefly describe the problems your child is experiencing.

Please briefly describe the problems you are 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 counseling?

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

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

Current Diagnosis

Diagnosis

History of the Problem

Approximately, when did your child first start experiencing the problem(s) or concerns that brought you to the office today?

Approximately, when did you first start experiencing the problem(s) or concerns that brought you to the office today?

How often does the problem or concern occur?

How long does it last?

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

No Yes

Do you have any thoughts of harming yourself or suicide?

No Yes

If yes, please explain

Has your child ever attempted to harm him/herself?

No Yes

Have you ever attempted to harm yourself?

No Yes

If yes, please explain

Does your child have any thoughts of harming someone else?

No Yes

Do you currently have any thoughts of harming someone else?

No Yes

If yes, please explain

Has your child ever attempted to harm someone else?

No Yes

Have you ever attempted to harm someone else?

No Yes

If yes, please explain

Has your child ever had previous therapy/counseling of any kind?

No Yes

Have you ever had previous therapy/counseling of any kind?

No Yes

If yes, when 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

Have you ever been hospitalized for emotional/behavioral problems?

No Yes

If yes, when/where was this

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

No Yes

Have you been prescribed medications to control emotional/behavioral/physical 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

Have you ever abused or experience (relational or legal) problems related to your use of drugs/alcohol?

No Yes

If yes, please explain

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

No Yes

Are you concerned that you have or maybe developing a problem with drugs/alcohol?

No Yes

If yes, please explain

Family

Has your 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.

Family Background

Have you experienced a separation, divorces, or death in your immediate or extended family?

No Yes

If yes, when?

Do you need help coping with this loss?

Please describe the circumstances.

As an adult or child have you experienced any issues related to physical/sexual abuse, inadequate nutrition, neglect, etc.)

No Yes

If Yes, describe

Please list the details of the client’s siblings (including those deceased, step, and half siblings):

Please list the details of your extended family members (including those deceased, step, & half siblings):

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

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Please list the details of your immediate family members (spouse & children,) who live in your household

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

No Yes

Has anyone in your family had treatment for emotional problems?

No Yes

If yes, please briefly explain (who/when)

Has anyone in your family ever attempted suicide or died of suicide?

No Yes

If yes, please briefly explain (who/when)

Has anyone in your family had treatment for issues with drugs/alcohol?

No Yes

If yes, please briefly explain (who/when)

Parenting, Discipline, & Family Roles

What do you use as discipline?

Does it work (explain)?

What else have you used in the past, and did it work?

Do you all guardians of the child agree on parenting/discipline styles?

No Yes

Explain

If you and the other parent are separated or divorced, how do you handle shared parenting?

If you are a single parent, how do you manage the stress of parenting alone?

How does your child respond to discipline?

What role does your child have in the home and how is this different from others in the home?

Who handles responsibility for your child in the following areas?

Specify

Cultural/Ethnic Background

To which cultural or ethnic group, if any, do you belong?

Are you experiencing any problems due to cultural or ethnic issues?

No Yes

If yes, describe

Other cultural/ethnic information

Spiritual/Religious Considerations

How important to your child are spiritual matters?

Not Little Moderate Much

How important are spiritual matters to you?

Not Little Moderate Much

Is your child affiliated with a spiritual or religious group?

No Yes

Are you affiliated with a spiritual or religious group?

No Yes

If yes, describe

Is your family affiliated with a spiritual or religious group?

No Yes

If yes, describe

Would your child like your spiritual/religious beliefs incorporated into the counseling?

No Yes

Would you like your spiritual/religious beliefs incorporated into counseling?

No Yes

If yes, describe

Family Health

Family Health Information

Describe father’s present health

Describe mother’s present health

Describe your siblings’ present health

Have any family members had any of the following (Please check if yes)?
If yes, please specify family member’s relationship to this child.

Have any family members had any of the following (Please check if yes)?
If yes, please specify family member’s relationship to you.

Health Condition

Cancer

Relationship to you

Tourette’s syndrome

Relationship to you

Diabetes

Relationship to you

Heart disease

Relationship to you

High blood pressure

Relationship to you

Behavior disorder

Relationship to you

Depression

Relationship to you

Mental Illness

Relationship to you

Mental retardation

Relationship to you

Nervousness

Relationship to you

Seizures/epilepsy

Relationship to you

Reading problem

Relationship to you

Speech/language problem

Relationship to you

Child’s Education

Current school

School phone number

Specify

Grade

Teacher(s)

School Counselor

In special education or have an IEP?

Yes No

If Yes, describe

In gifted program?

Yes No

If Yes, describe

Has child ever been held back in school?

Yes No

If Yes, describe

Which subjects does the child enjoy in school?

Which subjects does the child dislike in school?

What grades does the child usually receive in school?

Have there been any recent changes in the child’s grades?

Yes No

If yes, describe

Has the child been tested psychologically?

Yes No

If yes, describe

Check the descriptions which specifically relate to your child.

Feelings about School Work

Anxious

Passive

Enthusiastic

Rebellious

Eager

Fearful

Bored

No expression

Other

If Other, describe

Performance in School (Parent’s Opinion)

Satisfactory

Overachiever

Underachiever

Other

If Other, describe

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

Child’s Peer Relationships

Follower

Leader

Shares easily

Spontaneous

Makes friends easily

Long-time friends

Difficulty making friends

Other

If Other, describe

Child’s Work Experience:

If the child is involved in a vocational program or works a job, please fill in the following:

What is the child’s attitude toward work?

Poor Average Good Excellent

Current employer

Position

Hours per week

How have the child’s grades in school been affected since working?

Lower Same Higher

How many previous jobs or placements has the child had?

Usual length of employment

Usual reason for leaving

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 was the mother’s age?

Father’s age?

Length of pregnancy (weeks)

Birth weight (lbs, oz.)

Length of labor

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

This child was

breast fed

formula fed

both

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 or Learning 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

Where there other problems experienced during the child’s first year?

No Yes

If yes, describe

Compared with others in the family, child’s development was

slow average fast

Age for following occurrences (fill in where applicable)

Began puberty

Menstruation

Voice change

Convulsions

Breast development

Injuries or hospitalization

Issues that affected child’s development (e.g., physical/sexual abuse, inadequate nutrition, neglect, etc.) If Yes, describe

Child’s Medical Care History

Medical History

Child’s physician

Telephone

Client’s physician

Telephone

Address

How often does this child see a doctor?

Date of last visit

How often do you see a doctor?

Date of last visit

If Other, specify

List any current health concerns

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

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List any recent health or physical changes

Please check if there have been any recent changes in the following

Sleep patterns

Eating patterns

Behavior

Energy level

General disposition

Weight

Nervousness/tension

Physical activity level

Describe changes in areas in which you checked above

Examinations

(Please list all that apply below)

Examination Type

Last physical exam

Date

Reason

Results

Last doctor’s visit

Date

Reason

Results

Last vision exam

Date

Reason

Results

Last hearing exam

Date

Reason

Results

Most recent surgery

Date

Reason

Results

Other surgery

Date

Reason

Results

Upcoming surgery

Date

Reason

Results

Medications

Add new row

Allergic to any medications or drugs?

No Yes

If Yes, please describe.

Nutrition

Meal

Breakfast

How often (times per week)

Typical foods eaten

Lunch

How often (times per week)

Typical foods eaten

Dinner

How often (times per week)

Typical foods eaten

Snacks

How often (times per week)

Typical foods eaten

How often does your child exercise?

What activities?

How often do your exercise?

What activities?

Child’s Interests and Activities

Interests and Activities

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

No Yes

Are you involved in any extracurricular activities, such as sports or music programs, clubs or religious organizations?

No Yes

If yes, please describe.

Please describe your child’s strengths and positive characteristics.

Please describe your strengths and positive characteristics.

Other information you feel is important and wasn’t asked about.

Thank you for your time and cooperation,

Luke T Morrissey Ed.S.
Licensed Professional Counselor

Your information will be encrypted.

Client Intake Form

Child Intake Assessment Form

Adult Intake Assessment Form

Identifying Information

Client’s Information

Mother’s Information

Emergency Contact Information

Father’s Information

Step-Parent’s Information

Reason for Seeking Treatment

Current Diagnosis

History of the Problem

Family

Family Background

Parenting, Discipline, & Family Roles

Cultural/Ethnic Background

Spiritual/Religious Considerations

Family Health

Family Health Information

Child’s Education

Child’s Development

Child’s Medical Care History

Medical History

Examinations

Medications

Nutrition

Child’s Interests and Activities

Interests and Activities

Luke Morrissey, EdS, LPC

Licensed Professional Counselor