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  • Adolescent Initial Intake Form

  • Today's Date
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  • Format: (000) 000-0000.
  • Legal Custody: Do you have full custody and can make medical decisions?*
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  • How did you hear about us?*
  • May I have your permission to thank this person for the referral?*
  • If referred by another clinician, would you like for us to communicate with one another?*

  • Medical History

  • Sexual & Gender Identity*
  • Racial/Ethnic Identity*

  • Personal History

  • Please rank your concerns in the following areas on a scale of 1 to 10 (0 = No problems and 10 = Major problems). You may use the same number for more than one area.

  • School and Social Functioning

  • Do you have a learning disability? If so, what is the disability?*

  • More About You

  • Are you sexually active?*
  • Do you practice safe sex?*
  • Do you currently drink alcohol? If so, describe the type, amount, and how often (daily, weekly, monthly, etc.).*
  • Do you smoke cigarettes or use any nicotine products? If so, what and how often?*
  • Do you currently use recreational drugs? If so, describe type, amount, frequency.*
  • Have you ever been arrested for a D.U.I or other drug related offense? If yes, please give dates and details.*
  • Is it difficult for you to stop or control the amount you drink or use?*

  • Symptoms

  • Please check any symptoms that you currently experience or have experienced, and indicate when you experienced them.

  • Psychiatric History

  • Have you seen a mental health professional before? If so, please specify dates, the reason for counseling, and your experience. What was your diagnosis, if any?*
  • Do you have, or have you ever had, suicidal thoughts?*
  • Have you ever attempted suicide? Please list all attempts and your age when each happened, starting from the most recent event to the oldest event*
  • * Have you ever been hospitalized for a psychiatric issue? If yes, please describe why, when, and the length of your stay.*
  • Do any family members struggle with the following challenges? Please specify which family member.*

  • Family History

  • Should be Empty: