WCP Child and Family Intake Packet

Child and Family Intake Packet
Today’s Date

Month Day Year
Child's Information
Name

First Name Last Name
Birth Date

Month Day Year
Age
Gender
Ethnicity
Primary language spoken at home
First language(s) learned
Is your child right-handed, left-handed, or ambidextrous?
Please provide additional information about handedness, if relevant:
Primary Care Doctor
Parent #1 (person completing this form)
Name

First Name Last Name
Birth Date

Month Day Year
Age
Gender
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone

Area Code Phone Number
Email *
May Wolff Child Psychology leave a voicemail?

Yes No
May Wolff Child Psychology email you?

Yes No
Marital Status
Please explain:
Occupation
Highest level of education attained
Does the child have a 2nd parent with medical decision-making rights?

Yes No
Parent #2
Name

First Name Last Name
Birth Date

Month Day Year
Age
Gender
Address (if same as parent #1, do not fill out)

Street Address

Street Address Line 2

City State

Zip Code
Phone

Area Code Phone Number
Email
May Wolff Child Psychology leave a voicemail?

Yes No
May Wolff Child Psychology email you?

Yes No
Marital Status
Occupation
Highest level of education attained
General Family Information
Do the child's parents live together?

Yes No
Describe the child's living arrangements.
Who else lives in the child’s home(s)? Please provide each first name, relationship to child, and age.
Referral Information
What prompted you to seek therapy or an evaluation for your child?
What are your overall goals for therapy or the evaluation?
How did you learn about Wolff Child Psychology?
Birth and Developmental History
Were there any difficulties during pregnancy?

Yes No
Please explain:
Did the child's mother use any of the following during pregnancy (check all that apply)?

Tobacco Alcohol Other drugs
Describe the extent and timing of use.
Length of pregnancy (in weeks)
Birthweight (in lbs., oz.)
Mother's age at birth
Were there any difficulties during labor and/or delivery?

Yes No
Please explain:
Were there any medical problems noted at or immediately following birth?

Yes No
Please explain:
State the age (in months) at which your child did each of the following.
Sat alone
Stood alone
Walked alone
Began using single words other than mama and dada
Began using 2-3 word phrases
Describe any difficulties your child has had with the following.
Has your child currently or in the past had any difficulties with the following?

Toileting Eating Sleeping Activity Levels
Please explain:
Mental Health Information
Has your child worked with a psychologist before for therapy or evaluation?

Yes No
Tell us who you worked with and when, as well as what you learned.
Has your child received services from other providers (e.g., speech/language therapists, occupational therapists, etc.)?

Yes No
Tell us who you worked with and when, as well as what you learned.
Is your child currently taking prescribed psychiatric medications (e.g., ADHD medication, anti-depressant/anti-anxiety medication, etc.)?

Yes No
List the medication names and dosages.
Has your child previously been prescribed psychiatric medications (e.g., ADHD medication, anti-depressant/anti-anxiety medication, etc.)?

Yes No
List the medication names and dosages.
Is your child currently taking prescribed medications for any other health conditions (E.g., asthma, diabetes, etc.)?

Yes No
List the medication names and dosages.
Recently, how often has your child had thoughts of suicide and/or self-harm?

Never Rarely Sometimes Often
Please explain:
Recently, how often has your child hurt or attempted to hurt themselves?

Never Rarely Sometimes Often
Please explain:
In the past, how often has your child had thoughts of suicide and/or self-harm?

Never Rarely Sometimes Often
Please explain:
In the past, how often has your child hurt or attempted to hurt themselves?

Never Rarely Sometimes Often
Please explain:
Recently, how often has your child had thoughts about harming others?

Never Rarely Sometimes Often
Please explain:
In the past, how often has your child had thoughts about harming others?

Never Rarely Sometimes Often
Please explain:
Has your child ever been a victim of emotional, physical or sexual abuse?

Yes No
Please explain:
Has your child ever experienced other trauma (e.g., witnessing violence, involved in life-threatening accidents, etc.)?

Yes No
Please explain:
Have there been any recent major life stressors at home?

Yes No
Please explain:
Has your child ever been involved with the legal system?

Yes No
Please explain:
Other Health Information
Current height
Current weight
How is your child's overall physical health currently?

1

2

3

4

5

6

7

1 is Poor, 7 is Very Good
Has your child experienced any chronic health problems (e.g., asthma, diabetes, seizures) currently or in the past?

Yes No
Please explain:
Does your child have any allergies?

Yes No
Please explain:
Does your child have any medication allergies?

Yes No
Please explain:
How many hours of sleep does your child get each night, on average?
How much exercise/active time does your child get per day, on average?
Has your child ever used any of the following?

Alcohol Tobacco Other drugs
Describe, including what was used and how often, to the best of your knowledge.
Is your child sexually active?

Yes No
Has your child ever had a head injury, other serious injury, had surgery, or been hospitalized for any reason?

Yes No
Please explain:
Educational Information
Current School
Current Grade
Please explain:
List all schools previously attended, including grade levels.
Describe any developmental and/or educational concerns expressed by teachers in Preschool/Kindergarten.
Describe any developmental and/or educational concerns expressed by teachers since Kindergarten.
Has your child had an Individualized Education Program (IEP), 504 Plan, or a private school accommodation plan currently or in the past?

Yes No
Please explain (e.g., How long has your child had an IEP or 504 plan; What are the key supports/accommodations received, etc.).
Describe your child's current academic performance.
What are the easiest and hardest subjects for your child?
Social-Emotional Functioning
Describe your child's temperament/personality.
Describe your child's strengths and interests.
Describe your child's current social and/or emotional challenges.
How does your child prefer to spend their free time?
In what community and/or extracurricular activities is your child involved?
Family History

Has anyone in the child's immediate and/or extended family experienced the following? Please check "yes" if you know of or strongly suspect the presence of a disorder, even if it was never formally diagnosed. Then, list the family members by their relationship to the child (e.g., mother/father, brother/sister, grandmother/grandfather, aunts/uncles, cousins).

	Yes	No	Family Members
Intellectual Disability
Autism Spectrum Disorder
ADD/ADHD
Dyslexia
Other Learning Disability
Speech/Language Disorder
Seizure Disorder
Depression
Bipolar Disorder
Anxiety Disorders
Panic Attacks
Schizophrenia
Alcohol/Substance Abuse
Eating Disorders
Trauma History
Suicide Attempts
Psychiatric Hospitalizations

Has your child experienced the following?

	Current	Current Rating	Past	Past Rating
Depressed Mood or Sadness
Irritability/Anger
Mood Swings
Rapid Speech
Racing Thoughts
Anxiety
Worry
Panic Attacks
Phobias
Sleep Disturbances
Hallucinations
Paranoia
Poor Concentration
Alcohol/Substance Abuse
Physical Complaints
Eating Disorder Behaviors
Body Image Problems
Repetitive Thoughts
Repetitive Behaviors
Self-Harm

Please include any other information you would like us to know about your child.
Please click "Complete" if you are done with this form. *

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Child and Family Intake Packet

Child's Information

Parent #1 (person completing this form)

Parent #2

General Family Information

Referral Information

Birth and Developmental History

Mental Health Information

Other Health Information

Educational Information

Social-Emotional Functioning

Family History