CHILD/ADOLESCENT INTAKE FORM

Please Share electronic communication (Facebook, Twitter, SnapChat, Instagram, etc.) that you use:

Do your parents have access to your electronic communication? (Y/N) YesNo

Do they have any issues with your use of phone, text, electronic communication? (Y/N) YesNo

PERSONAL STRENGTHS

What activities do you enjoy and feel you are successful when you try:

Who are some of the influential and supportive people, activities (e.g. walking) or beliefs (e.g. religion) in your life?

CURRENT REASON FOR SEEKING COUNSELING

Briefly describe the problem for which you are seeking to have counseling for?

What would you like to see happen as a result of counseling?

COUNSELING/MEDICAL HISTORY

Have you previously seen a counselor? YesNo

If yes, what did you find most helpful in therapy?

If yes, what did you find least helpful in therapy?

CHEMICAL USE AND HISTORY

Do you currently use alcohol? YesNo

If yes, how often do you drink? DailyWeeklyOccasionallyRarely

If yes, how much do you drink? ____________ (#) per time.

Do you currently use Tobacco? YesNo

If yes, how much do you smoke/chew?

Do you currently use any other drugs? YesNo

If yes, what drugs do you use?

If yes, how often do you use? DailyWeeklyOccasionallyRarely

Have you received any previous treatment for chemical use? Y/N YesNo

If so, where did you go?

____Inpatient _________Outpatient InpatientOutpatient

Adolescents (please answer the following with Y/N)

1. Have you ever used more than 1 chemical at the same time to get high? YesNo

2. Do you avoid family activities so you can use? YesNo

3. Do you have a group of friends who also use? YesNo

4. Do you use to improve your emotions such as when you feel sad or depressed?? YesNo

Please list any legal issues that are affecting you or your family at present, or have had a significant effect upon you in the past.

1. Are your parents married or divorced?

2. Do you think their relationship is good? (Y/N/Unsure) YesNoUnsure

3. If your parents are divorced, whom do you primarily live with?

4. How often do you see each parent?

5. Did you experience any abuse as a child in your home (physical, verbal, emotional, or sexual) or outside your home? Please describe as much as you feel comfortable.

1. How do you consider yourself socially: outgoingshydepends on the situation.

2. Are you happy with the amount of friends you have? (Y/N) YesNo

3. Have you ever been bullied? (Y/N) YesNo

4. Are your parents happy with your friends? (Y/N) YesNo

5. Are involved in any organized social activities (e.g. sports, scouts, music)?

1. Do you like school? (Y/N) YesNo

2. Do you attend regularly? (Y/N) YesNo

3. What are your current grades?

4. Do you feel you are doing the best you can at School? (Y/N)

SYMPTOM NONEMILDMODSEVERE

SADNESS NONEMILDMODSEVERE

CRYING NONEMILDMODSEVERE

SLEEP DISTRUBANCES NONEMILDMODSEVERE

PROBLEMS AT HOME NONEMILDMODSEVERE

HYPERACTIVITY NONEMILDMODSEVERE

BINGING/PURGING NONEMILDMODSEVERE

LONELINESS NONEMILDMODSEVERE

UNRESOLVED GUILT NONEMILDMODSEVERE

IRRITABILITY NONEMILDMODSEVERE

NAUSEA/INDIGESTION NONEMILDMODSEVERE

SOCIAL ANXIETY NONEMILDMODSEVERE

SELF MUTALATION NONEMILDMODSEVERE

CUTTING NONEMILDMODSEVERE

IMPULSIVITY NONEMILDMODSEVERE

NIGHTMARES NONEMILDMODSEVERE

HOPELESSNESS NONEMILDMODSEVERE

ELEVATED MOOD NONEMILDMODSEVERE

MOOD SWINGS NONEMILDMODSEVERE

DISORGANIZED PANIC ATTACKS NONEMILDMODSEVERE

FEELING ANXIOUS NONEMILDMODSEVERE

FEELING PANICKY NONEMILDMODSEVERE

SUICIDAL THOUGHTS NONEMILDMODSEVERE

PAST SUICIDE ATTEMPTS NONEMILDMODSEVERE

OTHER NONEMILDMODSEVERE

APPETITE CHANGES NONEMILDMODSEVERE

SOCIAL ISOLATION NONEMILDMODSEVERE

PARANOID THOUGHTS NONEMILDMODSEVERE

POOR CONCENTRATION NONEMILDMODSEVERE

INDECISIVENESS NONEMILDMODSEVERE

LOW ENERGY NONEMILDMODSEVERE

EXCESSIVE WORRY NONEMILDMODSEVERE

ANGER ISSUES NONEMILDMODSEVERE

SPIRITUAL CONCERNS NONEMILDMODSEVERE

HALLUCINATIONS NONEMILDMODSEVERE

RACING THOUGHTS NONEMILDMODSEVERE

RESTLESSNESS NONEMILDMODSEVERE

DRUG USE NONEMILDMODSEVERE

ALCOHOL USE NONEMILDMODSEVERE

EASILY DISTRACTED NONEMILDMODSEVERE

TRAUMA FLASHBACKS NONEMILDMODSEVERE

OBSESSIVE THOUGHTS NONEMILDMODSEVERE

ANOREXIA NONEMILDMODSEVERE

GRIEF NONEMILDMODSEVERE

PHOBIAS NONEMILDMODSEVERE

HEADACHES NONEMILDMODSEVERE

WEIGHT CHANGES (UNPLANNED CHANGES) NONEMILDMODSEVERE

*We would like you to know that we have worked with a lot of adolescents and that we respect your privacy and we hope to create an atmosphere where you feel comfortable sharing*

CLIENT INFORMATION

PERSONAL STRENGTHS

CURRENT REASON FOR SEEKING COUNSELING

COUNSELING/MEDICAL HISTORY

CHEMICAL USE AND HISTORY

Adolescents (please answer the following with Y/N)

LEGAL ISSUES

FAMILY HISTORY

FAMILY CONCERNS (Please check any family concerns that your family is currently experiencing)

PEER RELATIONS

SCHOOL HISTORY

INDIVIDUAL CONCERNS

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