child/adolescent intake information - banyan tree … word - child confidential client...
TRANSCRIPT
Child/Adolescent Intake Information
Please fill out this evaluation completely. Your information will be held in strict confidence according to NC confidentiality laws and statute.
Child’s full name: ___________________________________________ Today’s Date:__________________
Date of birth: _____________________ Gender: M☐F☐ Race/Ethnicity: ______________________
Adult providing information today: __________________________________________________________
Child lives with: ☐Both Parents☐Mother☐Father☐Grandparent/s☐Other: __________
Child’s Legal Guardian/s: ___________________________________________________________________
Child’s Primary Address: ___________________________________________________________________
Child’s Primary Phone #: ______________________________ Who does phone belong to? __________
Child’s Pediatrician: _____________________________________________ Phone: ___________________
Referred by: ______________________________________________________________________________ Parent’s Demographics Current Caretakers: Mother’s name: ___________________________
Age: _____________
Full address: ______________________________
__________________________________________
Phone #’s: ________________________________
Email Address: ____________________________
Occupation: ______________________________
Employer: ________________________________
Highest level of education completed: _______
__________________________________________
Father’s name: ____________________________
Age: _____________
Full address: ______________________________
__________________________________________
Phone #’s: ________________________________
Email Address: ____________________________
Occupation: ______________________________
Employer: ________________________________
Highest level of education completed: _______
__________________________________________
*List EMERGENCY CONTACT with full name, relationship, and telephone number/s: __________________________________________________________________________________________
2
If child resides with someone other than biological parents (adoptive parent, foster parent, relative, biological mother and step-father, etc.), please explain this arrangement in detail: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list all individuals living in your child’s home, who these individuals are in relation to your child, and each individual’s age: __________________________________________________________________________________________
__________________________________________________________________________________________
Please note if you have any particular religious or spiritual beliefs that you would like me to be aware of, or incorporate into the counseling process: __________________________________________________________________________________________
__________________________________________________________________________________________
Presenting Issues Please indicate which of these issues are concerning you and your child today: ____ Depression, unhappiness ____ Few friends, loneliness ____ Anxiety/worry/nervousness ____ Social skill problems ____ Panic attacks ____ Anger management ____ Phobia(s) ____ Alcohol or substance abuse ____ Perfectionism ____ Academic performance problems ____ School behavior problems ____ Grief or Loss ____ Memory difficulties ____ Trauma ____ Family Conflict
____ Disorganization ____ Mood swings ____ Difficulty concentrating ____ Irritability ____ Procrastination ____ Lack of assertiveness ____ Time management problems ____ Sleep problems ____ Conflicts with parents ____ Appetite issues (over/under eating) ____ Lack of Self-esteem ____ Body image concerns ____ History of abuse ____ Excessive video game use ____ Bed wetting/Withholding bowels
Please list your child’s strengths and/or areas of success: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3
Please elaborate on the concerns you have about your child and how long you have been concerned: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please explain any high-risk behaviors your child may be currently engaging in or has engaged in in the past (i.e. aggressive behavior, drug/alcohol use, sexual activity, running away, etc.) __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please explain any legal problems your child currently has, or has had in the past (involvement with Juvenile Justice, court, probation, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
If applicable, please list any activities outside of school (sports teams, dance, church, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
Please state all methods of discipline you use with your child and if these methods have been successful: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please state what you hope to achieve, improve or make different through counseling: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4
Family Dynamics Please list all applicable disorders and/or conditions within your child’s biological family structure, including those of siblings, parents, grandparents, aunts/uncles, cousins, etc. (i.e. depression, anxiety, substance abuse, genetic disorders, neurological disorders, emotional/physical/sexual abuse, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please state if there have been any recent stressors or changes in your environment that may be affecting your child (divorce or marital problems, death in the family, move to a new home/school/neighborhood, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Child’s Developmental and Medical History Please list any problems during pregnancy and/or delivery of your child: __________________________________________________________________________________________
__________________________________________________________________________________________
Please state if your child was exposed to in utero stressors (i.e. mother under emotional stress, cigarettes, alcohol, or drugs while pregnant, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
Please classify your child’s early temperament (i.e. easy, quiet, stubborn, shy, difficult, active, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
Please list any developmental delays or problems your child had as an infant/toddler (i.e. weaning, walking, sitting up alone, toilet training, talking, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
5
Please list any problems your child has had, or currently has, with sleep, eating habits, elimination (i.e. difficulty with urination, bowel movements, soiling undergarments, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
Please list any medical conditions your child currently has, or has had in the past (i.e. ear infections, allergies, etc.): __________________________________________________________________________________________
__________________________________________________________________________________________
Please detail all of your child’s ER visits, hospitalizations, and surgeries (including child’s age, reason, and length of stay): __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Please list any medications your child routinely takes, or has taken in the past, and the reason for this medication: __________________________________________________________________________________________
__________________________________________________________________________________________
Last time your child had a physical exam: ____________________________________________________
Other Providers for Child (if applicable): Please list all current providers/agencies your child is involved with for counseling or mental health purposes. Please list the name of provider, telephone number, and what services you and/or your child are receiving: __________________________________________________________________________________________
__________________________________________________________________________________________
Please list any former providers/agencies who have seen you and/or your child for counseling or mental health treatment, including prior diagnoses your child received, when these services were received and from whom: __________________________________________________________________________________________
__________________________________________________________________________________________
6
Child’s School History Please state your child’s current grade, school, and primary teacher: _____________________________
__________________________________________________________________________________________
Please explain any identified special needs your child has at his/her school (i.e. 504 or IEP, psychoeducational testing results, etc.): ______________________________________________________ __________________________________________________________________________________________
__________________________________________________________________________________________
Please detail your child’s school history below: Place Date Location Concerns/Problems? Reason for Leaving Daycare
Preschool
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Is there anything else you would l ike me to know? What else would be helpful for your child in therapy? Please l ist ANY concerns or questions: __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________