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Child Intake Form

Client Name *:
Date Of Birth:
Address *:
Apt/Suite #:
City *:
State / Province *:
ZIP / Postal Code *:
Gender:
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:
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:

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