Increase Font
Decrease Font
Greyscale
Highlight Links
Regular Font
Reset
Search
Contact Us
Forms
Pay My Bill
Employee Portal
Board Portal
Translate
Accessibility
About Us
About Us
Leadership Team
Diversity, Equity, and Inclusion
60 Years of Solutions
Services
Mental Health
Outpatient Counseling
Family and Community Based Counseling
School Based Counseling
Specialist Counseling Areas
Children's Therapeutic Services and Support
Dialectical Behavioral Therapy
Trauma Focused Therapy
Family Stability
Domestic Violence Education & Support Groups
Family Access Center
Family Advocacy in Recovery and Restoration (FARR)
Family Involvement Strategies
Father Project
Guiding Partners to Solutions (GPS)
Voices for Children
Senior Independence
Chore and Support Services | Home Modifications and Repair
Neighbors Helping Neighbors Form
Caregiver Support and Respite Services
Meals On Wheels
Senior Cafe
Falls Prevention Home Safety Checks
Age-Friendly Olmsted County
Community Building
Age-Friendly Olmsted County
Guiding Partners to Solutions (GPS)
Rochester Non-Profit Consortium
Voices for Children - Child Abuse Prevention Council
Careers
Internships
Volunteer
Give
Events
Denim & Diamonds
Once Upon a Playhouse
Blog
Donate
Volunteer
Menu
Close
Child Intake Form
Client Name *:
Date Of Birth:
Address *:
Apt/Suite #:
City *:
State / Province *:
ZIP / Postal Code *:
Gender:
-- Select One --
Female
Male
I do not wish to say
Legal Custodian(s)
Mother:
Father:
Other:
Child Lives With:
Childs Health Information
Physical Health:
Important present/past illness, allergies, infectious diseases (optional), injuries, or handicap
Name Of Doctor:
City:
List of medications you are currently taking:
Name(s) of present or past psychologists/therapists seen:
Focus of sessions:
Would you like us to coordinate care with above named providers?:
Family History
Were your parents separated or divorced?:
If yes, how old were you?:
If you were raised by anyone other than your own parents, briefly explain:
How many brothers do you have?:
List all their ages:
How many sisters do you have?:
List all their ages:
Mother:
Father:
Has anyone in your family had problems with mental illness?:
If yes, please explain:
Lifestyle Choices
Smoking (how much /history ?):
Has your child had any legal charges? If so when:
What were the charges?:
What grade is your child in? (highest grade completed):
Current school attending?:
Child's Strengths
Please list the things your child does well/enjoys:
Sources Of Stress
Please list the thing/events/problems that are creating stress for your child at the present time:
What is the main concern you have as you see it?:
Please list the goals that you have for your child and /or family (be as specific as possible):
Is there any other information you feel is important?:
Emergency Contact #1
First Name *:
Last Name *:
Phone *:
Relation *:
Relative Contact #2
First Name:
Last Name:
Address:
City:
State / Province:
ZIP / Postal Code:
Phone:
Relation:
Parent/Guardian Information
First Name:
Date Of Birth:
Address:
City:
State:
Zip /Postal Code:
County Of Residence:
Phone Number:
Gender:
-- Select One --
Male
Female
Other
Race:
Marital Status:
Primary Language:
Other Language:
Military Status:
Military Service:
Employment:
Highest Education Level:
Household Income:
Household Size:
Have you or another member of your household received services from FSR before?:
If yes, please list here:
Please answer the following questions
Have you ever been concerned about your child’s temper?:
Has your child ever been depressed?:
Has your child ever been physically abused?:
Has your child ever been sexually assulted?:
Has your child ever attempted suicide?:
Has your child been hospitalized for emotional/mental illness?:
Do you have concerns about your child’s relationships?:
Information about Others (Parent, Siblings) in household:
Full Name:
Date Of Birth: