CHILD AND ADOLESCENT INTAKE FORM Stephanie

CHILD AND ADOLESCENT INTAKE FORM
Child's Name

First NameLast Name
Birth Date

MonthDayYear
REASONS FOR SEEKING EVALUATION OR THERAPY
Please provide a short description of the problems or concerns that have brought you to Child Development Associates:
FAMILY HISTORY
Parents are:

Married/Committed relationshipSeparatedDivorcedOther _______________________________________
If parents are not living together, what is the custody arrangement?
Who primarily meets the daily child care and/or parenting needs?
Please list all the people living in the household:

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child
Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade
If siblings or other immediate family are living outside the home, please list their names and ages:

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child
Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade
Parents’/Guardians’ current work statuses (e.g., full-time/part-time/not working; working from home, out of the house, hybrid model):
Family Cultural Background:
Religion(s) practiced in the home (if any):
Primary language spoken in the home:
Other languages:

Family Stressors: Please check all that apply.

	Past	Current
Marital conflict
Custody disputes
Financial problems
Job loss/changes
Parent using alcohol/drugs
Sibling emotional/behavioral problems
Legal issues
Housing problems
Significant moves
Death of relative or friend
Death of pet
Family accident or illness
Sibling rivalry/major conflict
Other stressors

If other stressors, please explain:
DEVELOPMENTAL HISTORY
How was the mother’s overall health during pregnancy?

GoodFairPoorDon't Know
Please describe any complications during pregnancy:
Please describe any labor, delivery, and/or birth complications:
As an infant or toddler, did you have any concerns with the following?

Feeding/ eating (including allergies)SleepAbility to be soothed/colickyOdd behaviors (such as rocking, head banging,clumsiness, daredevil acts)Adapting to transitionsSocial Interest (such as eye contact, responding to name, making noise to get attention)Emotional outbursts/temper tantrums
Please describe any concerns:
Have you or anyone else ever had concerns about this child’s development (i.e., fine motor, gross motor, speech/language, social/emotional)?

YesNo
If yes, please specify the concerns and your child received any services for these concerns (e.g., occupational therapy, speech therapy):
EDUCATIONAL HISTORY
Preschool:
Elementary School:
Middle School:
High School:
What are your child’s academic strengths?

Has your child had difficulty with any of the following? Please check all that apply.

	Past	Current
Reading
Arithmetic
Spelling
Writing
Time management
Attendance
Disciplinary actions

If any concerns, please explain:
RELATIONSHIP DEVELOPMENT

Please check items that describe your child.

	Past	Current
Prefers to be alone
Is alone a lot, but dislikes it
Is shy or timid
Has few friends
Has many friends
Plays/Spends time with “problem kids”
Is picked on/teased/bullied
Is oversensitive
Is more interested in objects than people
Poor relationships with teacher
Prefers spending time with adults
Is demanding and/or bossy
Fights with others
Teases/ bullies others
Plays/ Spends time with younger kids
Plays/ Spends time with older kids
Poor relationships with peers
Conflict with parents/step-parents
Excessive conflict with siblings

EMOTIONAL BEHAVIOR CHECKLIST

Please check items that describe your child

	Past	Current
Crying, sadness, depression
Loss of enjoyment in activities
Expressing a wish to die
Bedtime fears, won't sleep
Panics
Bites nails
Fidgets, unable to stay still
Unusual fears or phobias
Anxious, nervous
Is overly concerned about things
Twitches or unusual movements
Vocal/motor tics (e.g., repetitive eye blinking, throat clearing, facial movements, noises, etc.)
Withdrawn
Nightmares, night terrors
Low self-esteem
Injuries self (e.g., cutting, head banging)
Vomits intentionally
Low motivation
Problems with authority
Swears or uses obscene language
Easily annoyed by others
Blames others for own mistakes
Temper, Irritability, anger
Has threatened/attempted suicide
Disobedience
Argues a lot
Defiant
Has frequent tantrums
Wanting to run away
Sneaks out at night
Stealing
Lying
Hurts people or animals
Destroys property
Drug/Alcohol use
Repeats unnecessary act
Has rituals, habits, superstitions
Gorges or binge eats
Fasts to lose weight
Sleepwalking
Tiredness, fatigue
Restless sleep, wakes frequently
Trouble going to sleep
Sleeps too much
Poor appetite
Under or overweight
Over-activity
Frequently acts without thinking
Doesn't finish things
Disruptive
Short attention span, easily distracted
Daydreams, fantasizes
Is forgetful
Does not listen
Sexual problems
Concerns about identity
Hallucinations (i.e., hearing/seeing things that are not there)
Strange or unusual behavioral
Disorientation
Bedwetting/daytime wetting
Soiling (pooping) in pants

Engages in behavior that could be dangerous to him/herself

PastCurrent
Describe
Engages in behavior that could be dangerous to others

PastCurrent
Describe
Other concerning behaviors:

PastCurrent
Describe
PRIOR TREATMENT
Has your child ever received mental health services (evaluation or treatment)?

YesNo
If yes, please provide any diagnosis given and describe services:
Did you find it helpful?

YesNo
CHILD’S MEDICAL HISTORY
When was your child’s last physical examination?
How would you describe your child/adolescent’s health?

GoodFairPoor
How is his/her?
Hearing?

GoodFairPoor
Vision?

GoodFairPoor
Speech & language?

GoodFairPoor
Fine motor coordination?

GoodFairPoor
Gross motor coordination?

GoodFairPoor
Has your child/adolescent ever had chronic health problems (e.g., asthma, diabetes, allergies, heart condition)?

YesNo
If yes, please specify and provide age of onset:
Has your child/adolescent had any medical problems aside from the usual childhood illnesses, including injuries (e.g., concussions)?

YesNo
If yes, please specify:
If your child/adolescent has ever been hospitalized, what was it for?
If your child/adolescent has ever had surgery, what was it for?
Is your child/adolescent currently taking any medication?

YesNo
If yes, what medication(s):
This child/adolescent’s usual bedtime is at: time School nights time Weekends/vacation.
Describe this child sleep patterns or habits: Check all that apply.

Sleeps all night without disturbanceAwakens during night/restless sleeperGets out of bed in middle of the nightHas trouble falling asleepScreen time up to bedtimeSleeps with parent(s)Early morning awakeningSevere snoringWakes up tired
Describe this child’s eating habits:

OvereatsBinge eatsAverageRestricts intakeUnder eatsPicky eater
FAMILY MEDICAL HISTORY
Please identify any illness, medical condition, or disability that any member of the immediate family has had (e.g., heart disease diabetes, cancer).
Please note any family history of substance abuse, mental illness, or learning disability (e.g., anxiety,depression, suicide, hospitalizations in mental institutions, abuse).
OTHER INFORMATION
What are your child’s favorite activities?
Is your child currently employed or work during school breaks?

YesNo
If yes, where and how many hours/week?
Do you have concerns about your child's technology use?

YesNo
If yes, please explain:
What disciplinary techniques do you usually use when your child behaves inappropriately?

Ignore problem behaviorScold childSpank childRedirect child’s interestRevoke privilegesSend child to his/her roomThreaten consequencesReason with childTime outDon’t use any techniqueOther
Which disciplinary techniques are usually effective?
What type of disciplinary techniques are usually ineffective?
What have you found to be the most satisfactory ways of helping your child?
What are your child’s strengths and unique qualities?
If your child has experienced any painful experiences (e.g., significant losses, traumas), please describe:
COVID-19 has had a dramatic impact on the lives of everyone, and it led to big changes in the lives of children and families. While there are some similarities across families, everyone’s experience has been unique. Please describe any notable changes your child experienced (either positive or negative) during the COVID pandemic, in any of the following areas: health, education, family, social.
Is there any other information that you think may help us in working with your child?
Who referred you to us?
6 Palmer Avenue | Scarsdale, NY 10583 | 914-723-2228
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