Family Intake Form

New Client Information Packet

Name:(Required)

Today’s Date:

MM slash DD slash YYYY

Date of Birth

MM slash DD slash YYYY

Age

Gender:

Male

Female

Other- Specify

Gender:

Person completing this form:

Relationship to Client:

E-mail(Required)

Parent Information:

Parent #1

Name

Phone Number:

Address:

Employer/Occupation:

Parent #2

Name

Phone Number:

Address:

Employer/Occupation:

Are parents separated or divorced?

Yes

If yes, please describe the custody arrangement and provide

documentation:

Contact Information:

Patient Home Address:

City

State:

Zip:

Telephone:

Home

OK to contact?

Yes

OK to leave message?

Yes

Cell:

OK to contact?

Yes

OK to leave message?

Yes

Work:

OK to contact?

Yes

OK to leave message?

Yes

Emergency Contact:

Relationship:

Phone Number:

Current Situation:

What are your main reasons for seeking therapy for your loved one? (Be as specific as you can)

When did this problem start?

Are there other concerns that you have regarding their development or current functioning?

Yes

If so, please describe:

Please check if there has been any recent changes in the following:

Sleep patterns

Physical activity level

Eating patterns

General disposition

Behavior

Weight

Focus

Energy level

Nervousness/Tension

Other

What are your main goals in coming to The Forum?

What do you believe are your child's main strengths?

What do you believe are your child's main weaknesses?

School Information:

Name of School:

Client's grade level:

School Counselor's Name:

Please describe their grades:

Please check all that apply to your child's education below:

Documented Learning Disability

Gifted and Talented Program

Specialized Classroom Instruction

Home School or Alternate Learning Environment

Individualized Education Plan (IEP)

Behavior Support Plan

Specialized School or Day Program

Tutoring Services

504 Plan

SST Meetings

Remedial Classes

Counseling (School based)

Other

Please describe any boxes checked, giving as much detail as possible

How would you describe your child’s functioning in school? (ex. Gets along well with others, responsive to instruction, defiant, shy, outgoing, attendance, etc.)

Does your child have any behavior or academic problems in school?

Yes

If so, please describe:

Current Medical Information:

Does your child have health concerns?

Yes

If yes, please list any current health concerns:

Please list all current medications (Name, dose, frequency, reason):

Please describe any medical issues or serious injuries or illnesses (past, present):

Medical and Developmental History:

Was the pregnancy planned?

Yes

Is your child adopted?

Yes

Please describe your pregnancy and any prenatal complications (include any unusual stressors or medical issues for your child’s mother during pregnancy):

How often were prescription drugs, cigarettes, alcohol, illegal drugs used during pregnancy (please describe):

Please describe your child’s birth and any complications:

Did your child meet developmental milestones (walking, talking, eating, toileting, etc.) as expected? List any exceptions:

What medical conditions has your child experienced since birth (check all that apply)?

Abdominal pain

Appendicitis

Head injury

Broken bone

Bedwetting

Chronic cold/cough

Dental problems

Dizziness

Whooping cough

Asthma

Heart problems

Poor appetite

Nosebleeds

Unusual movements

Tonsillitis

Thyroid problems

Surgery or Hospitalization

Allergies

Ear infection

Tic

Frequent urination

Vision problems

Constipation

Breathing difficulties

Seizures

Fainting

Frequent headaches

Measles

Overeating

Diabetes

Sinusitis

Tuberculosis

Vomiting

Anemia

High fever

Trouble sleeping

Bronchitis

Chest pain

Chickenpox

Diarrhea

Eating problems

Fatigue

Hearing problems

Mumps

Mononucleosis

Sore throat

Stroke

Loss of consciousness

Cancer

Other

Does your child have any history of significant trauma?

Yes

If so, please provide details:

Is there any history of the following?

Physical Abuse?

Yes

Sexual Abuse?

Yes

Domestic Violence Between Parents?

Yes

If yes, please explain:

Previous Treatment

Has your child ever seen a counselor or therapist in the past?

Yes

If yes, how long ago and why did treatment end?

Has your child ever received a psychological or developmental evaluation?

Yes

If yes, by whom and when?

Has your child ever received a diagnosis for a psychological ordevelopmental disability?

Yes

If yes, what was the diagnosis?

Please check behaviors and symptoms that occur to your child more often than you would like them to take place:

Aggression

Anger

Anxiety

Avoiding people

Avoiding school

Bedwetting

Boredom

Cheating

Crying

Homework difficulties

Cyber addiction

Depression

Dieting

Distractibility

Dizziness

Eating disorder

Drug Use

Fatigue

Elevated mood

Focus problems

Hallucinations

Lying

Cursing

Hopelessness

Impulsivity

Judgment errors

Loneliness

Irritability

Low self-esteem

Heart palpitations

Memory impairment

Mood shifts

Nightmares

Panic attacks

Phobias/fears

Sexual behavior

Sick often

Stealing

Speech problems

Sleeping problems

Suicidal thoughts

Texting

Trembling

Throwing things

Tummy ache

Social Media Issues

Worrying

Yelling

Withdrawing

Non-suicidal self-injurious behaviors (cutting, burning, etc.)

Other