Child Intake Form

Personal Information

Please provide the following information and answer the questions below. All information you provide here is protected as confidential information.

Name

First and Last

Date

Parent/Legal Guardian (if under 18):

Address

City

State

Zip code

Home Phone

Cell/Work/Other Phone

*Please note: Email correspondence is not considered to be a confidential medium of communication

Date of Birth

Age

Gender

Identification Please upload your ID or any form of identification

Add file

Please upload a file

Who does the child live with?

Mom Dad Both

Ethnicity/Race

Native American Hispanic Asian White Black Indian Middle Eastern Other

Please list any other children and their ages that live in the home or are siblings (step or half):

Insurance Information

Insurance Company

Employer

Policy Holder

Relationship

Date of Birth

Insurance Card Please upload both front and back of inurance card

Add file

Please upload a file

History

Who referred you? Or How did you learn of my office?

Previous therapist/practitioner

If yes, please list:

List all prescribed and over the counter medication your child is currently taking?

General and Mental Health Information

1. How would you rate your child’s physical health?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific health problems they are currently experiencing:

2. How do you rate his/her current sleeping habits?

Poor Unsatisfactory Satisfactory Good Very good

Please list any specific sleep problems they are currently experiencing:

If yes, please explain.

4. What grade is your child in?

How are their grades?

5. Outside of school, what other sports, interest or hobbies does your child engage in?

8. Please list any difficulties with your child’s appetite or eating patterns.

If yes, please provide details:

10. Who normally disciplines your child?

If yes, for approximately how long?

If yes, for how long?

If yes, please describe

14. What is the primary reason you would like your child in therapy?

15. What would you like to see accomplished in these therapy sessions? Please include any other concerns or issues you may have regarding your child.

16. What do you consider to be some of your child’s strengths/ weaknesses?

Your information will be encrypted.