New Client - Child

Mental Health and Medical History

New Client Child - Intake Form
Describe any stressors that might be affecting your child now (i.e. death, divorce, trauma).
Has your child participated in psychological or educational testing with a licensed psychologist?
Has your child been diagnosed with any behavioral, educational, medical, neurological or psychiatric disorder, such as Attention Deficit/Hyperactivity Disorder (ADHD), Learning Disorder (LD), Anxiety or Depression? (if yes, please specify below)

Previous Mental Health Treatment or Evaluation

	Date(s)	Therapist/Facility	Reason for Seeking Treatment/Evaluation
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If currently prescribed medications, please provide Psychiatrist or prescribing physician's information

Current Medications

When was your child's most recent medical exam?
Does your child have any vision, hearing (including ear infections), speech or coordination problem? (if yes, please explain the problem and treatment)
Indicate any significant illnesses/conditions that your child has had and treatment received for these conditions.
Has your child ever been taken to the Emergency Room or been admitted to the hospital? (if yes, please list reason and age of child at the time)
Does your child display any unusual sensitivities to bright light, loud sounds and/or touch?
Does your child have any sleeping difficulties (i.e. trouble falling asleep, staying asleep, waking)?
Does your child have any unusual eating patterns or habits?

Parental Information

If parents are separated/divorced, who has primary physical custody of the child?
Age of child at separation/divorce:
Describe the current custodial and visitation arrangements.

Adults, siblings and/or others living in the family home:

	Name	Age	Relationship to Child	Problems with behavior, learning, or psychiatric?
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2
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What was the child's birth order:blanks out of blank .
Is there a family history of mental health issues in the child's biological family? (i.e. ADHD, learning problems, depression, anxiety, bipolar disorder, schizophrenia, substance abuse, etc.)? (If yes, please describe)
Child's Birth and Developmental History
Were there any problems with the pregnancy or birth of your child? Did the biological mother use any tobacco, medication, street drugs or alcohol while pregnant with the child? (If yes, please describe below.)
Did your child have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)? (If yes, please describe below.)

Educational History

New Client Child - Intake Form
Did you or any teachers have concerns about your child's early education school performance? (If yes, please describe below)
Please describe your child's significant strengths and weaknesses in their academic performance.
Has your child changed schools for reasons other than normal academic progression? (If yes, please describe below)
Has your child skipped or repeated any grades in school? (If yes, please describe below)
Do you or any teachers have any concerns about your child's recent academic performance?
Has your child's performance or attitude towards school changed in the last two years? (If yes, please describe below)
Does your child have any special needs or accommodations at school? Does your child receive any special services at school?

Behavior and Social Skills

New Client Child - Intake Form
Do you have any concerns regarding your child's behavior either at home, in school or in the community? (If yes, please describe below.)
How do you handle discipline in your family? Do you feel that these methods are successful in managing your child's behavior?
About how many close friends does your child have?

1-3 4-6 7+ Other
Please list your child's extracurricular activities or social organizations.

Confirmation and Signature

New Client Child - Intake Form
Is there any other information that you think may help me in understanding and working with your child?
My signature below indicates that I have voluntarily and accurately completed this form. A photocopy of this agreement will be considered as valid as an original.
Parent/Legal Guardian Name (completing this form) *

First Name Last Name
Signature of Parent/Legal Guardian Name (completing this form) *

Clear
Today's Date *

Month Day Year
Please verify that you are human *
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Mental Health and Medical History