Teen/Child Intake Form
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- Alvin Fox
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1 Date: Client Name: Person completing form (e.g., parent/guardian: Teen/Child Intake Form DOB: Relationship: If you are unable to answer any of the questions below, please write DK (Don t Know in the blank provided. ETHNICITY (optional: Caucasian African American Hispanic Native American Asian Bi/Multiracial Other: HOUSEHOLD Intimate Relationship never been in a serious relationship not currently in serious relationship currently in a serious relationship not currently looking for serious relationship Relationship Satisfaction very satisfied satisfied somewhat satisfied very dissatisfied dissatisfied List all persons currently living in child s household Name Age Sex Relationship to child List children and stepchildren not living with child Name Age Sex Freq of visit/relationship Describe any past or current significant issues in intimate relationships : HISTORY FAMILY OF ORIGIN Present during Childhood: Mother Father Stepmother Stepfather Brother(s Sister(s Other: Present entire childhood: Present part of childhood: Not present at all: Parent s current marital status: Married to each other for years Separated for years Divorced for years Mother remarried times Father remarried times Mother involved with someone Father involved with someone Mother deceased for years (your age at mother s death: Father deceased for years (your age at father s death: Describe parents: Father: biological adoptive step other Full name: Occupation: Education: General health: Mother: biological adoptive step other Full name: Occupation: Education: General health: Family Attachment and Counseling Center of Minnesota, Inc C Minnetonka Blvd. Deephaven, MN tel: fax
2 Describe child s family experience: outstanding home environment normal home environment chaotic home environment alcoholic/addicted parent(s poverty (serious financial problems witnessed or was aware of physical/ verbal/sexual abuse (circle all that apply Page 2 of 6 T/C experienced physical/verbal/sexual abuse from others (circle all that apply Describe any abuse the child has experienced: Other difficult experiences the child has had: Age of emancipation from home: Circumstances: Describe any past or current signific ant issues in other immediate family relationships: DEVELOPMENTAL HISTORY (check all that apply to child s development Problems during mother s pregnancy: Birth: none normal delivery high blood pressure difficult delivery bed rest cesarean delivery alcohol use complications: drug use cigarette use other Birth weight: Infancy: feeding problems sleep problems toilet training problems colic other: Childhood health: lead poisoning (age: ear infections head injury (list age and describe: other significant injury (list age and describe: asthma (age diagnosed seizures (type and ages: hearing loss (age diagnosed and severity: impaired vision not corrected by lenses (age diagnosed: surgeries (ages and type: chronic, serious health problems: Delayed developmental milestones (check only those that were not reached at expected age: sitting engaging peers walking rolling over tolerating separation speaking standing toilet training riding bicycle Social interaction (check all that apply to child: normal social interaction isolated self very shy dominated others inappropriate sex play had acting out friends other: Emotional/behavior problems (check all that apply to child: drug use disobedient alcohol abuse distrustful stealing hostile/angry often sad impulsive violent temper indecisive immature hyperactive extreme worrier self-injurious acts fire-setting anxious easily distracted frequently daydreamed Intellectual/academic functioning (check all that apply to child: normal intelligence mild retardation high intelligence moderate retardation special education from to for authority conflicts attention problems Current or highest education level:
3 SOCIO-ECONOMIC HISTORY (check all that apply Living situation: Employment: housing adequate employed and satisfied homeless employed but dissatisfied housing overcrowded unemployed dependent on others for coworker conflicts housing change jobs a lot housing dangerous/ disabled: deteriorating Financial situation: no current financial problems large indebtedness poverty impulsive spending relationship conflicts over finances Page 3 of 6 T/C Social support system: supportive network few friends substance-use-based friends no friends distant from family of origin living companions dysfunctional Legal history no legal problems now on parole/probation arrest(s not substance-related arrest(s substance-related court ordered this treatment jail/prison time(s; total time served: describe last legal difficulty: Sexual history : heterosexual orientation homosexual orientation bisexual orientation currently sexually active not currently sexually active currently sexually dissatisfied history of unsafe sex: ages to age first sexual experience: age first pregnancy or fatherhood: history of promiscuity: ages to Cultural/Spiritual/Recreational history: Cultural identity (e.g. ethnicity, religion: Describe any cultural issues that contribute to current problem: Yes No Active in community/recreational activities? Was active in community/recreational activities? Currently engage in hobbies? Currently participate in spiritual activities If answered yes to any of the above, describe: Name and city of church attended: Describe any other developmental problems or issues: MEDICAL AND PSYCHOLOGICAL HISTORY Primary Care Physician: ` Phone: Psychiatrist (if any: Phone: Describe current physical health: Good Fair Poor List any current medical conditions : List any known allergies: Describe any serious hospitalization or accidents. Include Date, Age, and Reason Has child previously taken medication to treat psychological problems? no yes (include below List any medications currently taken: Medication Reason Dosage Freq Start/End Date Physician Side Effects Beneficial? Which of the following areas of functioning have been impaired by psychological problems? (Check all that apply Occupational Academic Social Affective (Emotional Physical
4 Is there a history of any of the following in the family? tuberculosis mental retardation birth defects heart disease emotional problems high blood pressure behavior problems alcoholism thyroid problems drug abuse cancer diabetes Page 4 of 6 T/C Alzheimer s disease or dementia stroke other chronic or serious health problems: Has any family member ever received a psychiatric diagnosis or psychological treatmen t (inpatient or outpatient? No Yes (describe below Has any family member ever taken medication for a psychological problem? No Yes (describe below SUBSTANCE USE HISTORY (check all that apply Family alcohol/drug abuse history : father sibling(s mother spouse/significant other stepparent/live-in children uncle(s/aunt(s other grandparent(s Substance use status: no history of abuse active abuse early full remission sustained full remission sustained partial remission Issues related to substance abuse: hangovers assaults seizures binges blackouts job loss overdose arrests suicidal impulse sleep disturbance withdrawal symptoms medical conditions tolerance changes loss of control of amount used relationship conflicts Substances used: Alcohol amphetamines/speed barbiturates/owners caffeine cocaine crack cocaine hallucinogens (e.g, LSD heroin inhalants (e.g., glue, gas marijuana or hashish nicotine/cigarettes PCP prescription: other: First use age: Current use? (Yes/No Last use age: Frequency Amount PREVIOUS TREATMENT PSYCHIATRIC HOSPITALIZATIONS AND TREATMENT (INCLUDING CD TREATMENT Prior outpatient psychotherapy or counseling? No Yes If yes, complete the following : Age at time Psychotherapist/Counselor (Agency, City Duration Circumstances for treatment Is child currently seeing any of the above? No Yes If yes, please include name here:
5 Severe Moderate Mild None Severe Moderate Mild None Prior hospitalizations or inpatient treatment for psychological or CD issues? No Yes If yes, complete the following : Age at time Hospital/Treatment Center Duration Circumstances for treatment PREVIOUS DIAGNOSES Has child ever been diagnosed with a psychiatric, substa nce abuse, learning, emotional, or behavioral disorder?? No Yes If yes, complete the following : Diagnosis Age Diagnosis made by Agree? CURRENT SYMPTOM CHECKLIST (Rate the intensity of the symptoms present in the last two weeks None = This symptom is not present at this time Mild = This symptom is currently impacting my quality of life, but not significantly impairing my day-to-day functioning Moderate = This symptom is significantly impacting my quality of life and/or day-to-day functioning Severe = This symptom is profoundly impacting my quality of life and/or day-to-day functioning Symptom Symptom Depressed mood Low energy Sleep disturbances Dissociation Hyperactivity Bingeing Decreased sex drive Unresolved guilt Irritability Nausea/acid indigestion Social anxiety Self-mutilation/cutting Impulsive actions/speech Nightmares Elevated mood Losing train of thought Mood swings Disorganized Anorexia Social isolation Grief Phobias Headaches Loneliness Problems at Home Increased or decreased appetite Unplanned weight gain Unplanned weight loss Paranoid thoughts Poor concentration/indecisive Purging/over-exercising Excessive worrying Low self-worth Anger management problems Tension Hallucinations Racing thoughts Restlessness Loss of interest in normal activity Decreased creativity/productivity Unresolved anger Easily distracted Memories of trauma Hopelessness Marital problems Panic attacks Suicidal thoughts Feel panicky/anxious Work problems Has attempted suicide in the past Briefly describe how the above symptoms impair the child s ability to function: Family Attachment and Counseling Center of Minnesota, Inc C Minnetonka Blvd. Deephaven, MN tel: fax
6 ENVIRONMENTAL STRESSORS (check all that apply and are current or recent Death of a family member Death or loss of a friend Health problems in family Inadequate social support Disruption of family by separation Living alone Disruption of family by divorce Difficulty with acculturation Disruption of family by estrangement Discrimination Marriage stress Adjustment to life cycle transition Removal from the home Illiteracy Remarriage of parent Academic problems Sexual abuse Discord with teachers or classmates Physical abuse Unemployment Parental overprotection Threat of job loss Neglect of a child Stressful work schedule Inadequate discipline Job dissatisfaction Discord with siblings Job change Birth of a sibling Discord with boss or coworkers Birth of a child Homelessness Page 6 of 6 T/C Inadequate housing Unsafe neighborhood Discord with neighbors or landlord Extreme poverty Inadequate finances Insufficient welfare support Inadequate healthcare Inadequate health insurance Recent arrest or incarceration Involved in litigation Victim of a recent crime Exposure to war, disasters, or other hostilities Discord with counselor, social worker, physician or other caregiver Other PRESENTING PROBLEMS Please state any reasons for seeking therapy. For each problem please include any additional relevant information including the length of time this has been a problem Therapist use only
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