Teen 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

Do you live with both of your biological parents?

Yes No

Ethnicity/Race

Native American Hispanic Asian White Black Indian Middle Eastern Other

Marital Status

Never Married Domestic Partnership Married Separated Divorced Widowed

Referred By (if any)

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?

If not, whose idea was it?

How do you feel about coming here?

What do you think your family will say the problem is?

What do think the problem is?

What do other people like about you?

What don’t you like about yourself?

What don’t other people like about you?

Name the three things in your life that upset or bother you the most

What else do you enjoy doing?

Are there activities that you would like to do but are afraid to do?

If yes, why?

What do you hate doing?

What makes you feel happy?

What makes you feel sad?

What makes you feel scared?

What do you worry about?

What keeps you from feeling happy?

What do you wish could be different (change) in your life?

If yes, When?

What did you do?

If yes, Who?

Legal

If yes, how many times?

How did you get into trouble?

If yes, How long?

Counseling

If yes, explain?

When?

Where?

Why?

If yes, explain?

School

How do you feel about going to school?

How much effort do you make in your classes and on your homework to get good grades?

What do you do when you skip class?

If yes, what are they?

Employment

Where do you work?

How many hours per week?

Religious/Spiritual

If yes, what are they?

Sex

When was your first sexual experience?

Do you have any sexual problems or worries? Do you have any sexual problems or worries?

Drinking/Drug Usage

If yes, since what age?

How many cigarettes do you smoke in a day?

If yes, since what age?

What did you get high on?

What do you drink or use now to get high?

How much (amount) do you consume or use now?

How much have you used in the last 2 days?

What do they think or what would they think about you drinking or getting high?

If yes, Why?

Family/Responsibility/Relationships

Who are you closest to in your family?

Who don’t you get along with in your family?

Why don’t you?

What chores do you have to do at home?

What do you parents do when you break the rules or neglect your chores?

Are you having any problems with your family?

Are you having any boyfriend or girlfriend problems?

Additional Information

If yes, what is your current employment situation?

Do you enjoy your work? Is there anything stressful about your current work?

If yes, describe your faith or belief:

3. What do you consider to be some of your strengths?

4. What do you consider to be some of your weaknesses?

5. What would you like to accomplish out of your time in therapy?

Your information will be encrypted.