Child & Youth Intake Form

Child & Youth Intake Form

Sol Play Child Therapy Inc - Owned by Shirla de Magalhães, LMFT, RPT-S,RSP License 82947 - 8453 La Mesa Blvd, La Mesa, CA 91942- 619-797-6595 www.solplaytherapy.com
Today’s Date

Month Day Year
Date
Referred by
Preferred pronoun for child:

He, Him, His She, Her, Hers They, Them, Theirs
Child's Name *

First Name Last Name
Date of Birth

Month Day Year
Date
Age
Child's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
School
Grade
Health Insurance Carrier
Policy #
Co-Pay
Deductible to be met
Has your deductible been met?

Yes No Not Sure
Name of Primary Insurance Holder
For Tricare Only: Social Security # of Sponsor
Primary Doctor
Primary Doctor Phone #
Psychiatrist (if applicable)
Psychiatrist Phone #
Parent/Guardian Information:
Name of Parent 1

First Name Last Name
Parent 1 Phone #
Please enter a valid phone number.
Date of Birth

Month Day Year
Date
Preferred pronoun for Parent 1:

He, Him, His She, Her, Hers They, Them, Theirs
E-Mail
example@example.com
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Can Therapist contact this parent by (select all that apply):

Cell Phone Text E-mail Mail
Currently Employed?
Occupation
Employer
Hours per week
Name of Parent 2

First Name Last Name
Tel
Date of Birth

Month Day Year
Date
Preferred pronoun for Parent 2:

He, Him, His She, Her, Hers They, Them, Theirs
E-Mail
example@example.com
Address (if different than child)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Can Therapist contact this parent by (select all that apply):

Cell Phone Text E-mail Mail
Currently Employed?
Occupation
Employer
Hours Per Week
Please list any Step Parents:
If Parents are divorced, please describe Legal & Physical Custody Agreement and/or Visitation Schedule.
Observation: If parents are divorced, copy of the current custody agreement must be shown to therapist, and signed or verbal consent by both parents must be given prior to start of treatment.
Emergency Contact:

First Name Last Name
Emergency Contact Phone #
Please enter a valid phone number.
Please list names and ages of family members living in the home(s):
If Child was adopted, age child was placed with you.
Cultural Heritage:
Any Spiritual Practice?
What brings your child to therapy?
What goals do you have for your child In therapy?
Were there any problems or difficulties with the pregnancy or delivery of the child?
Did Mother have Postpartum Depression?
If yes, how long did it last?
During pregnancy, did the mother use any of the following (select all that apply):

Tobacco Street Drugs Alcohol Unknown
During pregnancy, did the mother experience any stress (i.e. a new job, move, etc)? Were there any family crises such as marital separation, divorce, death in family, etc?
Did your child meet the following milestones:

Rolling Over (2-6 months) Sitting (6-12 months) Standing (8-16 months) Walking (8-16 Months) Engaging Peers (24-36 months) Potty Trained (24-36 months) Dressing Self (24-36 months) Feeding Self Sleeping Alone Tolerating Separation Playing Cooperatively Speaking
Please add any observations regarding child's developmental milestones:
Child’s temperament as a baby: easy-going, cuddly, irritable, etc...
What are your child's strengths?
What do you love about your child?
Medical/Mental:
Has your child participated in therapy before?

Yes No
Names of any previous therapists, dates of service, and briefly describe that experience.
Please list any current medication child is taking, dosage, frequency.
Please list any hospitalizations with dates.
Any current or past suicidal ideation or attempt? Any history of self harm?
Date of Last Doctor's Visit
Please list any medical concerns
Please describe any history of trauma (sexual, physical, emotional, accidents, hospitalizations, etc...)
Please describe any diagnosed or undiagnosed mental illness in family members.
Socialization/Recreational:
Please describe child's relationship with family members.
Please describe child's relationship with peers.
What does child do for fun? (hobbies, interest, sports, activities, clubs, etc...)
Educational/Vocational:
Any Educational Concerns (grades, attendance, behaviors at school, etc...?)
Does child have an IEP or 504 Plan?
Please describe your child's overall experience, and or challenges during these school years:
Daycare / Pre School
Elementary School (please add school(s) attended) :
Middle School (please add school(s) attended) :
High School (please add school(s) attended) :
Name of parent who completed this form.
Signature

Clear
Should be Empty:

Child & Youth Intake Form

Parent/Guardian Information:

Medical/Mental:

Socialization/Recreational:

Educational/Vocational:

Please describe your child's overall experience, and or challenges during these school years: