Family Intake Form New Client Information PacketName:(Required) Today’s Date: MM slash DD slash YYYY Date of Birth MM slash DD slash YYYY AgeGender: Male Female Other- Specify Gender: Person completing this form: Relationship to Client: E-mail(Required) Parent Information:Parent #1Name Phone Number:Address: Employer/Occupation: Parent #2Name Phone Number:Address: Employer/Occupation: Are parents separated or divorced? Yes no If yes, please describe the custody arrangement and providedocumentation: Contact Information:Patient Home Address: City State: Zip: Telephone:HomeOK to contact? Yes No OK to leave message? Yes No Cell:OK to contact? Yes No OK to leave message? Yes No Work:OK to contact? Yes No OK to leave message? Yes No 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 no 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? 1 2 3 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 no If so, please describe: Current Medical Information:Does your child have health concerns? Yes no 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 no Is your child adopted? Yes no 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 no If so, please provide details: Is there any history of the following? Physical Abuse? Yes no Sexual Abuse? Yes no Domestic Violence Between Parents? Yes no If yes, please explain: Previous TreatmentHas your child ever seen a counselor or therapist in the past? Yes no If yes, how long ago and why did treatment end? Has your child ever received a psychological or developmental evaluation? Yes no If yes, by whom and when? Has your child ever received a diagnosis for a psychological ordevelopmental disability? Yes no 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 Does or has your child use(d) any of the following? Coffee/Caffeinated Beverages/Energy Drinks If so, describe frequency and amount Does or has your child use(d) any of the following? Cigarettes If so, describe frequency and amount Does or has your child use(d) any of the following? Alcohol If so, describe frequency and amount Does or has your child use(d) any of the following? Marijuana If so, describe frequency and amount Does or has your child use(d) any of the following? Other Drugs If so, describe frequency and amount Please describe concerns related to drug/alcohol use: Does your child engage in disordered eating behavior?Does your child engage in disordered eating behavior? Yes No Unknown If yes, please check all that apply: Restricting Binging Purging Extreme Diets Other How does he/she feel about their body? How much physical activity does he/she engage indaily? Social and Behavioral Information:Please check all that apply as it relates to how your child gets along with other people: Aggression Harms self Difficulty making/keeping friends Underactive Tantrums Respectful Hyperactive Runs away Difficulty finishing a task Sadness Impulsivity Separation difficulties Oppositional Sensory sensitivities Trouble with the law Inattentive Property destruction Self-stimulatory behavior Affectionate Arguing Often Shy/Withdrawn Rigid/Controlling Friendly Leader Submissive Other Other Please describe any concerns you have regarding your child’s social and behavioral functioning: Does your child get teased?Untitled Yes No Does your child tease others?Does your child tease others? Yes No Please describe any behavioral challenges you have with your child at home (challenging times of day, outbursts, homework difficulties, etc.): Please describe discipline strategies you use with your child: Do you feel like they are effective? Cultural Information:To which cultural or ethnic group(s) does your family identify? Any members in the family experiencing any problems related to cultural or ethnic issues?Untitled Yes No If yes, please describe: Language(s) spoken in the home: Preferred Language: Religious/Spiritual:How religious or spiritual is your family? (Circle the number that describes him/her best) 1 2 3 4 5 6 7 8 9 10 untitled Very Somewhat Not at all Is your family affiliated with a spiritual or religious group? Yes No Which group? Is there anything else you would like your therapist to know? Who referred you to The Forum?(Required) NameThis field is for validation purposes and should be left unchanged.