ChildIntake Form

Basic Information

Child's Name*

Child's Date of Birth*

Email Address*

Referred by

Reason Seeking Evaluation*

Family Information

Mother's Information

Mother's Name

Mother's Age

Mother Lives With Child?

Yes No

Mother's Marital Status

Married Single Divorced Widowed

Mother's Marital History

Mother's Employment

Father's Information

Father's Name*

Father's Age

Father Lives With Child?

Yes No

Father's Marital Status

Married Single Divorced Widowed

Father's Marital History

Father's Employment

Others In Household

Medical Information

Child's Pediatrician

Is the child on meds?

Yes No

Current Medical Problems/Medications

Allergies

Mental Health History

Is the child in counseling?

Yes No

Medication History

Is the child on psychotropic medication?

Yes No

Has the child ever been hospitalized

Yes No

When/Where/How long ?

Recent Stressors

Problem Assessment

Duration of Problem

How it Affects child

How it Affects Family

How it Affects School Work

How it Affects Friendships

What Makes It Better?

What Makes It Worse?

Problems now / in the past - please describe:

Excessive worries

Sleep

Appetite

Hyperactivity

Compulsive Behaviors

Drug/Alcohol Abuse

Excessive Crying

Hallucinations (Hearing/Seeing Things)

Unusual or Strange Thoughts

Temper Tantrums

Fighting

Excessive lying or stealing

Extreme mood changes

Suicidal Thoughts / Actions

Additional Medical History

Any history of seizures / head trauma / neurologic problems / lead exposure / heart problems / lung problems / endocrine problems?

Is there anyone in the child's biological family that has had depression, attention deficit disorder, obsessive compulsive disorder, bipolar disorder, learning disability, schizophrenia, or any other psychological disorder?

Does anyone in the child's family have a substance abuse problem? If yes, please describe:

Developmental History

Were there any complications in the pregnancy, delivery or early medical problems? If yes, describe:

Did the child have any early difficulties with feeding, sleeping, colic? If yes describe:

Child's Primary Caretaker*

Did the child have any delays in motor or speech development? If yes, describe:

Child's age at toilet training

How long did it take?

Was it easy or difficult?

School and Social History

Did the child attend preschool? If yes, were there any problems with the separation from parents, aggression toward other children or any concerns at that time?

Was the child ever the victim of physical, sexual or verbal abuse? If yes, describe:

Was the child ever involved with Child Protective Services? If yes, describe:

Did the child ever witness domestic violence? If yes, describe:

School Child Attends

Grade

Is the child receiving special education services?

Does the child have any friends?

Yes No

How would you describe your child's ability to get along with other children:

Is the child invited to birthday parties, sleepovers, etc.?

Child's relationship with other adults:

Does the child have hobbies, participate in sports, school clubs, scouts, etc.?

Child's best qualities:

What would you most like to be different for your child?