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  • English (US)
  • Child and Adolescent Intake Questionnaire

  • In order to determine the best approach for helping your child, it would help to have information about your family and your child's problems. Therefore, it is requested that the parent(s) or guardian(s) complete this questionnaire as completely as possible before the first appointment.  We are also asking for insurance information and requesting you read Patient Policies and HIPAA information. 

    Don’t worry if you are unable to recall all information requested. Good guesses or general answers are acceptable. Anticipate 20-30 minutes to complete this form. There is a SAVE button at the bottom if you need to stop and come back to complete the form.

    This questionnaire will be submitted electronically through a confidential HIPAA compliant portal directly to The Meridian Group and will only be seen by your child's clinician.

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  • Information on Mother / Guardian 1

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  • Information on Father / Guardian 2

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  • Symptom Checklist for Child

  • Background Information and Current Functioning

  • At approximately what age did your child do the following? (These may be difficult to remember; estimates are acceptable).


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  • Thank you for completing this quesionnaire.  It will be helpful in the assessment and treatment of your child or adolescent. 

  • Should be Empty: