ALCS Child Intake Form (Parent/Guardian)
Thank you for choosing Abundant Life Counseling Services, P.A. So that we can better assist your teen, please fill out this form as fully and openly as possible. All information is held in strictest confidence within legal limits. If certain questions do not apply, you can leave them blank.
Information Supplied By:
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First Name
Last Name
Relationship to Child:
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Who is the child's ALCS counselor?
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Kerry Williamson, MA, LPC-S, LMFT-S, CST
Carolyn Dixon, MSW, LCSW
Rachelle Honohan, MSW, LCSW-S
Regina Gray, MS, LPC
Nicole Parker, MA, LPC
Linlee Carbajal, MS, LPC
Julie O'Brien, MA, LPC-Associate Supervised by: Kerry Williamson, MA, LPC-S, LMFT-S, CST
How did you hear about us?
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Identifying Information
Child's Full Name
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First Name
Last Name
Nickname (if any)
Date of birth
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Month
-
Day
Year
Date
Gender
Male
Female
Age
Race & Ethnicity
School Attending
Grade
Name(s) of Parent(s) / Guardian(s)
With whom does the child live?
Primary guardian(s)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
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Area Code
Phone Number
Work Phone
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Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
May we call you at the phone number(s) provided above? Check all that apply.
Yes, you can call my cell phone
Yes, you can call my work phone
Yes, you can call my home phone
Please do not call me
May we leave you a voicemail at the phone number(s) provided above? Check all that apply.
Yes, you can leave a voicemail on my cell phone
Yes, you can leave a voicemail on my my work phone
Yes, you can leave a voicemail on my home phone
Please do not leave a voicemail
Your Email Address
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example@example.com
May we email you at this email address?
*
Yes
No
Does the child attend church regularly?
Yes
No
Name and denomination of church
Personal Concerns
Please describe the concerns you have about your child and the reasons you are seeking help.
When were these difficulties first noticed? Please explain as fully as you can.
List the child's behaviors that you would like to see changed .
List his/her three greatest strengths .
List his/her three greatest weaknesses or areas of improvement .
Briefly describe his/her ways of expressing the following: (1) Anger, (2) Happiness, (3) Sadness, (4) Anxiety.
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Behaviors of Concern
Please check how often the following behaviors occur:
Never
Rarely
Sometimes
Frequently
1. Loses temper easily
2. Argues with adults
3. Refuses adults' requests
4. Deliberately annoys people
5. Blames others for own mistakes
6. Easily annoyed by others
7. Angry (recently)
8. Spiteful/vindictive
9. Defiant
10. Bullies/teases others
Please check how often the following behaviors occur:
Never
Rarely
Sometimes
Frequently
11. Initiates fights
12. Uses a weapon
13. Physically cruel to people
14. Physically cruel to animals
15. Stealing
16. Forced sexual activity
17. Intentional arson
18. Burglary
19. "Cons" other people
20. Runs away from home
Please check how often the following behaviors occur:
Never
Rarely
Sometimes
Frequently
21. Truant at school
22. Doesn't pay attention to details
23. Several careless mistakes
24. Does not listen when spoken to
25. Doesn't finish chores/homework
26. Difficulty organizing tasks
27. Loses things
28. Easily distracted
29. Forgetful in daily activities
30. Fidgety/squirmy
Please check how often the following behaviors occur:
Never
Rarely
Sometimes
Frequently
31. Difficulty remaining seated
32. Runs/climbs around excessively
33. Sexually active
34. Hyperactive
35. Difficulty awaiting turn
36. Interrupts others
37. Problems pronouncing words
38. Poor grades in school
39. Expelled from school
40. Drug use
Please check how often the following behaviors occur:
Never
Rarely
Sometimes
Frequently
41. Alcohol consumption
42. Depression
43. Shy/avoidant/withdrawn
44. Suicidal threats
45. Suicidal attempts
46. Fatigued
47. Anxious/nervous
48. Excessive worry
49. Sleep disturbance
50. Panic attacks
51. Mood shifts
For each of the behaviors noted above as occurring FREQUENTLY, or if it causes significant impairment, write a brief description of how it impacts the child's or other people's lives. Please give examples.
Has the child had any previous professional assistance with the problems stated here?
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Yes
No
First time in counseling: Who was the counselor?
First time in counseling: What was the problem?
First time in counseling: How many sessions, when, over what period of time?
First time in counseling: What were the results?
Second time in counseling: Who was the counselor?
Second time in counseling: What was the problem?
Second time in counseling: How many sessions, when, over what period of time?
Second time in counseling: What were the results?
Third time in counseling: Who was the counselor?
Third time in counseling: What was the problem?
Third time in counseling: How many sessions, when, over what period of time?
Third time in counseling: What were the results?
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Family History
Mother's Name
Mother's Age
Mother's Occupation
Father's Name
Father's Age
Father's Occupation
If parents are separated or divorced, how old was the child when this happened?
Is your child adopted?
Yes
No
Are they aware of the adoption?
Yes
No
If divorced or adopted, describe your relationship with the child's other biological parent(s) .
Has the child ever been in foster care?
Yes
No
Please list when, where and all pertinent information.
Family history of mental illness:
Family history of drug/alcohol use:
Please list all family members currently living at home or closely connected with the family. Indicate their ages, relationship to this minor and their school grade or occupation.
Name
Age
Relationship
Grade/Occupation
1
2
3
4
5
6
7
8
Does this child have any siblings not presently living with them? Please explain.
How does this child get along with his/her brothers or sisters?
Describe any special activities you do with this child.
List his/her main difficulties at home.
Describe how the child is disciplined.
For what reasons is the child disciplined?
Social Development and Peer Relationships
What special interests, hobbies, sports, and games does the child enjoy, both in and after school?
When your child chooses friends, are they... (pick all that apply)
Older?
Younger?
Same Age?
Boys?
Girls?
Other
In activities, is the child a leader, follower, or loner?
Does the child prefer the company of adults to other children?
Yes
No
Does the child have at least one best friend?
Yes
No
What is the friend's age?
How many hours a day does your child spend on social media?
How many hours a day does your child spend on technology in general?
Do you have any concerns about your child’s use of social media or technology? If so, please briefly describe below:
Emotional Development
Please check any and all that family members, teachers or others have used to characterize your child:
Restless/Inattentive
Humorous/Fun
Cheerful
Daydreamer
Immature
Aggressive
Forgetful
Quick to Anger
Depressed/Sad
Disruptive
Happy
Nervous/Tense
Other
Has your child experienced any type of trauma? Check all that apply:
Physical Abuse
Sexual Abuse
Psychological/Emotional Abuse
Human Trafficking
Witnessed Domestic Violence
Car Crash
Dating Violence
Robbery or Assault
Bullying
Witnessed Homicide
Death of Close Family Member or Friend
Other
Please provide a brief description.
School History
Briefly describe how your child is doing in school. Please note areas of strength and weakness in school.
What grades do they usually receive?
Have these grades changed recently? If so, how?
Has your child...
Had extended or frequent absences
Had to repeat a grade
Changed schools mid-year
Started the school year at a new school
If you checked any of the above, please explain the circumstances.
Has your teen had any remedial help or special education services in school or privately?
Yes
No
Please describe and give approximate ages.
How does the adolescent get along with the teacher and other students in school?
List the child's main difficulties at school.
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Health Information
Please describe your child's general health.
Do they currently have any serious illnesses, injuries or handicaps?
Please list all important past illnesses, accidents, injuries or handicaps:
Please give reasons and approximate dates for any hospitalizations:
Are there any conditions that require regular medical care?
Were there any complications at birth?
Was your child full-term?
Yes
No
Child's weight at birth
Length of hospital stay
Did Mother experience post partum depression?
Did your child meet all their development milestones appropriately?
Yes
No
Please describe.
Does he/she have any difficulties with vision or hearing? (Please note date and results of any previous vision or hearing exams)
Do they have any allergies? If yes, please identify.
How many hours does your child sleep each night?
Do they experience food cravings?
Yes
No
For which types of foods?
Has your child gained or lost weight in the past three months?
Yes, they gained weight.
Yes, they lost weight.
Their weight is the same.
How much weight was gained / lost?
Ex: 10 lbs gained
How would you rate your child's diet?
Very Healthy
Healthy
Average
Needs Improvement
Poor
Are they currently taking medications?
Yes
No
If so, please complete the following.
Medication
Dosage
Frequency
Purpose
Physician
1
2
3
4
5
6
Pediatrician / Primary Care Physician Name
Physician's Phone Number
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Area Code
Phone Number
Date of last physical exam
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Month
-
Day
Year
Date
Date of last routine check-up
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Month
-
Day
Year
Date
Is your child currently using any drugs or alcohol for recreational purposes?
Yes
No
Unsure
Please list drug and/or alcohol use.
Substance
Amount
Frequency
1
2
3
4
5
6
Please give any additional information that you believe would be helpful.
Emergency Contact
Whom should we contact in case of emergency?
Full Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
*
-
Area Code
Phone Number
Work Phone
-
Area Code
Phone Number
Home Phone
-
Area Code
Phone Number
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