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Counseling Intake Form
Hi there, please fill out and submit this confidential form to help us meet your needs.
22
Questions
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1
Your Name
First Name
Last Name
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2
Email
example@example.com
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3
Child's Name
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4
What is your primary reason for seeking services for your child?
Please be as detailed as you can.
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5
What are your child's goals for counseling?
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6
Is this your child's first time in therapy? If not, please describe their previous experience.
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7
What are the biggest challenges your child is facing at school?
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8
Describe your family's living situation.
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9
Describe your child's developmental history.
(Did they start to walk, talk, etc. on time? Were there concerns? Describe any developmental milestones not met on time.)
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10
What is your child's gender identity?
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11
Has your child every been hospitalized for a psychiatric issue?
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12
Is there a history of mental illness in your family?
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13
Specify all medications and supplements your child is presently taking and for what reason.
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14
If your child is taking prescription medication, please list the prescribing MD.
Include name and phone number.
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15
Has your child witnessed any domestic violence?
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16
Has your child experienced any significant life stressors or trauma?
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17
Is there a history of substance abuse in the family?
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18
Has your child ever expressed thoughts or urges to harm others?
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19
Has your child ever expressed suicidal thoughts?
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20
Has your child ever attempted suicide?
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21
What are your child's strengths?
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22
What else would you like me to know about your child?
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