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.

Child's Name *

First Name Middle Name Last Name Suffix

Date of Appointment

Month Day Year

Name of Your Clinician *

John Dwyer, PhD, Licensed Clinical Psychologist Melissa Findlay, LCSW, Licensed Clinical Social Worker David Epstein, PsyD, Licensed Clinical Psychologist Elizabeth Novak, LCSW, Licensed Clinical Social Worker Jill Sexton-Newton, LPC, Licensed Professional Counselor Julianne Luck, MSW, Supervisee in Social Work No one chosen yet

Who referred you to our office?

Primary care provider

If no primary care provider, enter "none"

May we contact the Primary Care Provider for coordination of care?

Yes No PCP No

Age

Date of Birth *

Month Day Year

Gender

Male Female

Grade in school

School name

If your child is working, where and in what position?

Insurance company(s) that covers child

Previous and current mental health treatment Including counseling, testing, and medication. When and by whom?

Type "None" if there has been no previous mental health treatment

Current medications. Who prescribes them?

Mother / Guardian Name *

Age

Cell Phone Number *

Area Code Phone Number

Alternate Phone Number

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email *

example@example.com

Highest Educational Level

Occupation

Father / Guardian Name

Age

Cell Phone Number

Area Code Phone Number

Alternate Phone Number

Area Code Phone Number

Address (type "same" if same as Parent 1)

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Email

example@example.com

Highest Educational Level

Occupation

With Whom Does the Child Live?

Both Parents / Guardians Mother/Guardian 1 Only Father/Guardian 2 Only Divorced 50/50 Visitation Divorced Primarily with One Parent/Guardian, Visitation with the other Parent/Guardian

If other, please list the name, address, phone number, and nature of relationship (e.g. grandparent, other relatives, foster care)

Name(s), Genders, and Ages of Siblings (including step and half siblings living in the home). Do any of them have behavioral, attention, or emotional problems?

Name of Step Parent or Partner of Divorced Parent Living in the Home (eg (stepmother, father's girlfriend, etc.)

As completely as possible, please describe the problems you feel your child is experiencing and the reason you are bringing your child for services. Please include how long these problems have been occurring.

Does your child have the following problems (please check all that apply).

What do you think may be causing your child's problem(s)?

Describe the course of pregnancy (complications, etc.).

Describe the delivery (anesthesia, cesarean, complications). Describe the infant's condition at birth.

What was your family's situation surrounding the time of your child's birth?

Please describe any medical or developmental problems.

e.g.: Surgeries, Hospitalizations, Broken Bones, Eustation Tubes, Failure to Thrive, Significant Illness, Asthma, Allergies, Developmental Delay

Does your child have problems with sleep? If they do please describe.

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

Sat Up

Age In Months

Walked Alone

Age in Months

Toilet Trained During the Day

Age in Years

Toilet Trained During at Night

Age in Year - Mark 0 if still a problem

If not toilet trained day or night, please describe.

Has your child ever received or been considered for for special education services? If yes, what type of services and for what grades? Do they currently have an IEP or 504 Plan?

How does your child currently do in school? (academic & behavior).

Briefly describe your child's school history including academic work & behavior (summarize across grades if academics and behavior did not change).

How does your child get along with peers and siblings.

How would you describe your child's personality.

Is your child involved activities after school with peers? Do they have hobbies or other interests?

(e.g. sports, scouts, show choir, gaming, computers, fishing, online media, fashion, karate, crafts)

Has either parent lived apart from the child for any extended period of time? If so, when and for how long. If parents are separated or divorced, what is the visitation schedule?

Describe any past traumatic or stressful psychological events experienced by your child.

e.g. significant medial history, abuse, death of family member or friend, medical problem, divorce, loss of a pet

Has any member of the extended family experienced any significant emotional or behavioral problems?

Parents, sibling, grandparents, or other close relatives

Does anyone living with this child have drug or alcohol problems? Who is the person and the nature of their problem?

Does this child use or used in the past alcohol, tobacco, or illegal drugs?

No Alcohol Marijuana Vaping / Smoking Prescription Drugs Not Prescribed (provided by someone else)

If the answer is not no, please elaborate.

List family moves and their dates since birth of this child.

How would you describe your marriage or relationship with spouse, partner, boyfriend or girlfriend ? How long have you been together? On what issues do you disagree?

What type of discipline do you use for your child and how does it work?

How have you explained to your child that you are bringing him/ her to see a therapist?

Additional comments or remarks you would like to share.

Your Signature (use mouse, finger tap, or digital pen)

Clear

Name of individual completing this questionnaire and relationship to child.

Date completing questionnaire

Month Day Year

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

Child and Adolescent Intake Questionnaire

Information on Mother / Guardian 1

Information on Father / Guardian 2

Symptom Checklist for Child

Background Information and Current Functioning