Child/Adolescent Intake Form
Patient Information
Minor Client Name
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First Name
Last Name
Age
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Date of Birth
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Month
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Day
Year
Date
Grade
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Name of Caregivers
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Area of Concern
Please describe reasons for seeking therapy
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When did you first notice this/these difficulties arising?
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How has/have these challenges affected your functioning at:
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Home
School/work
In relationships
Please list goals and expectations for treatment.
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Psychological History
Please describe any symptoms of depression (excessive sadness/crying, irritability, hopelessness, sleep difficulties, extreme anger, social withdrawal/isolation)
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Please describe any symptoms of mania (abnormal energy level, reduced need for sleep, pleasure seeking, racing thoughts, increase in risk taking activity, too talkative, grandiosity)
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Please describe any symptoms for anxiety (excessive worry, frequent fear, restlessness, sleep difficulties, compulsive behaviors and/or obsessive thoughts, frequent illness and/or aches, racing heart and/or thoughts)
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Please describe any symptoms for behavioral problems (argumentative, physical aggression, truancy, property destruction)
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Please describe symptoms for Inattention/Hyperactivity (highly/easily distracted, difficulty being still, impulsive, incompletion of tasks)
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Please describe any symptoms for disordered eating (bingeing, restricting food, distorted body image, laxative abuse, bulimic behavior, excessive exercise)
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Please describe any symptoms of trauma-related difficulties (recurring dreams/nightmares, intrusive/recurring memories/flashbacks, dissociation, one or several exposures to/experiences with physical, sexual, mental abuse and/or neglect)
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Please describe any symptoms for psychosis (hearing voices, seeing things, paranoia, delusions)
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Have you experienced any abuse/neglect? If yes, please describe.
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Have you ever harmed yourself? If yes please explain
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Have you seriously contemplated and/or attempted suicide? If yes, please explain
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Have you seriously contemplated and/or attempted homicide? If yes, please explain
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Please describe sleepy hygiene (hours of sleep, difficulty staying sleep, difficulty awakening, restlessness, nightmares)
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Have you received mental health treatment in the past? If yes, please note when/where
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Do you use or have you used substances and/or alcohol? If yes please explain
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Is there a family history of mental illness? If yes, please check the following
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Anxiety
ADHD
Bipolar
Schizophrenia
Alcohol/drugs
Learning Disabilities
Autism/Asperger's/PDD
Intellectual Disabiity
Psych hospitalizations
Suicide (or attempts)
Panic Disorder
Post Traumatic Disorder
Obsessive Compulsive Disorder
Other
None
Developmental and Medical History
Did you achieve the following milestones early, average or late compared to toher your age? If late, please explain
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Language (using words, sentences)
Fine Motor skills (drawing circle, building with blocks)
Gross motor skills (rolling over, standing, walking)
Toilet Training
Have you experienced any regression of any of the above? If yes, please explain
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Please describe pregnancy/birth. Please include important factors that occurred during pregnancy/birth
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Please describe medical history. Include all important conditions
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Have you ever experienced a head injury, loss of consciousness, or seizure? If yes, please describe
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Academic and Social History
Please describe academic performance
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Please describe your relationships with family members (both positive and negative)
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Please describe relationships with peers (same and opposite sex)
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Please describe relationship with adults
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Other Pertinent Information
Do you have a religious and/or spiritual belief system? If yes please share
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Have you ever experienced challenges regarding race, religion, ethnicity, sexual identity, disability? If yes, please share
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Are you sexually active?
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yes
no
Do you work?
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yes
no
Have you ever been detained, arrested, or on probation? If yes, please explain
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Client signature if over 12
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Parent/Guardian Signature
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Today's Date
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Month
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Day
Year
Date
Submit
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