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1 Hope in Healing Counseling and Wellness, LLC Stacy Nunne, MA, LAMFT, RN KleinBank Building Mailing Address: PO Box West 78th Street, Suite 10B Chanhassen, MN Chanhassen, MN Phone: Fax: website: Adolescent Psychotherapy Intake To be Completed by Adolescent This form is intended to help your counselor become better acquainted with you and in turn, serve you better. You may omit any item, but try to be as thorough as possible. Please use the back if you need more space. Thank you. Client Name: Nickname: Date: Date of Birth: Age: Gender: Male Female Grade in school: What brings you to therapy?: My current concerns/symptoms developed (Please Circle): Suddenly (less than four weeks) Gradually (one to several months) Very Gradually (one to several years) How would you describe your mood at this time?: What would you like to see change as a result of therapy? Have there been any significant changes in your life recently? Yes No If yes, please describe: What do you hope that will be different in your life as a result of coming to therapy?: Do you have any concerns at this time about hurting yourself? No Yes If yes, please describe: Do you have any concerns at this time about hurting someone else? No Yes If yes, please describe: Family Environment/Relationships Your Living Situation I live with: Biological Parents Adoptive Parents Parent and Step-Parent Foster Parents One Parent Alone Relatives Other: Primary Household Household Age Relationship Describe Relationship Member Name to me Do you live in more than one household? No Yes If no, skip to Secondary Household. If yes, complete the secondary household information. Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 1 of 6
2 Secondary Household Household Age Relationship Describe Relationship Member Name to me Additional family members living with you Household Age Relationship Describe Relationship Member Name to me How would you describe your family?: What does your family do together?: Describe how problems are generally handled in your family?: Where did you live growing up? (Please list all places): Have you experienced a death (family, friends, pets, etc.)? No Yes At what age(s)? If yes, please describe your reaction: Development History Are there special, unusual, or traumatic circumstances that affected your development? No Yes If yes, please describe: Do you have a history of abuse? No Yes If yes, which type(s): Sexual Physical Verbal Emotional Neglect Inadequate Nutrition Inadequate Medical Attention Inadequate Dental Attention Is there anything else that happened to you that you consider abuse?: Did anyone in your family of origin experience childhood abuse? No Yes If yes, Whom: Mental Health Treatment History Have you experienced or witnessed any of the following? No Yes (Please check all that apply to you) Car accident Community violence Bullying Domestic violence/abuse Other accident Fire Natural disasters Significant loss Physical illness Relationship Abuse Recent Death Loss of friendships Other: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 2 of 6
3 Behavioral/Emotional Health (Please check all of the following that apply to you): Affectionate Expect Failure Moody Slow Moving Aggressive Fatigued Neat/Orderly Speech Problems Anger Problems Fearful Nightmares Steal Anxiety Fearless Overweight Stomachaches Argue Excessively Frequent Injuries Phobias Stutter Avoids Adults Frustrated Daily Preoccupied with Things Teeth Grinding Bully/Threaten Others Generous Quiet or Withdrawn Tics or Twitching Careless/Reckless Have Bad Dreams Sad Tired Often Clumsy Hopelessness Selfish Underweight Confident Impulsive Self-Mutilation Unsafe Behaviors Cooperative Irritable Separation Anxiety Unusual Thinking Depressed Lazy Set Fires Withdrawn Destructive Learning Problems Short Attention Span Worry Excessively Difficulty Speaking Loner Shy/Timid Other Defiant Low Self-Esteem Sick Often Other Enthusiastic Messy Sleeping Problems Other Please describe any of the above or any other concerns: Alcohol or Drug/Chemical Use - Please list the alcohol or drugs/chemicals that you have used - list how much: Never Used Used in the Past Age Started Daily Weekly Occasionally Last Use Caffeine Tobacco Alcohol Marijuana/THC Cocaine/Crack Inhalants/ Huffing LSD/ Shrooms Prescribed Pills Heroine Speed, Ecstasy Rohypnol-Roofies GHB-liquid ecstasy LSD Steroids Others: Others: If you use alcohol or Drugs/Chemicals: Do you have any concerns about your use of alcohol? No Yes Drugs/Chemicals? No Yes Do you believe that you have a problem with alcohol? No Yes Drugs/Chemicals? No Yes If yes, how long have you gone without using alcohol or drugs/chemicals? Are others concerned about your alcohol use? No Yes Drugs/Chemical use? No Yes Whom? Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 3 of 6
4 Have you ever been in treatment for alcohol or chemical dependency? No Yes If yes, where? Treatment Center/Hospital (Include inpatient, outpatient, detox) Dates Did you learn anything that was helpful? No Yes Please describe what you found to be helpful: Are you currently seeing a psychiatrist? No Yes Psychiatrist: Is he/she helpful?: Have you ever been hospitalized for psychiatric reasons? No Yes Hospital Reason for Hospitalization Dates Have you ever been under the care of a therapist? No Yes If so, with who and when? Therapist Approximate Dates Helpful? Is there a family history of a problem with alcohol? No Yes Drugs/Chemicals? No Yes Please indicate A-alcohol D- Drugs/Chemicals Mother Father Sibling Maternal Grandmother Paternal Grandmother Sibling Maternal Grandfather Paternal Grandfather Sibling Maternal Aunt Paternal Aunts Other Maternal Uncle Paternal Uncles Other General Health Information (Please put C-Current and/or P-Past for all that apply to you): Abdominal pain Diabetes Headaches Skin Problem ADHD Disability Heart trouble Sleeping Problems Allergies Dizziness Memory Impairment Speech Problems Asthma Excessive Sweating Migraines Stomach Trouble Neck/Back pain Eye Problems Numbness/Tingling Tics/Tremors Blackouts Fainting Spells Pain-Where? Wears glasses Chest Pains Fatigue Respiratory illness Other Colds/Coughs Hearing Loss Seizures Other Dental problems Head Injury Severe Head Injury Other Please list any current health concerns or problems OR any changes in your health?: Have you ever had any seizures or head injuries? No Yes If yes, please describe: Please check if you have noticed/experienced any recent changes in the following: Sleep patterns Eating patterns Behavior Energy level Physical activity level General disposition Weight Nervousness/tension Please describe: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 4 of 6
5 Sexual History Are you currently sexually active? No Yes Have you been sexually active in the past? No Yes Do you have any concerns about your sexual development? No Yes Please explain: Education Current school: How long attended?: Type of school: Public Private Home schooled Other (please specify): Grade: Teacher: School Counselor: Previous Schools: Do you have any learning problems?: Which subject/areas interest you the most in school?: Which subject/areas interest you the least in school?: What grades do you typically receive in school?: Have there been any changes in your grades? No Yes If yes, please describe: Performance in school (by your report): Satisfactory Underachieve Overachieve Please check below the words that best describe you in regards to school performance: Anxious Disorganized Interested Responsible Bored Eager Lack of Initiative Self-Directed Cooperative Enthusiastic Organized Sloppy Disinterested Industrious Passive Does only what is expected Other (please describe): Do you have any problems with teachers or other classmates? No Yes If yes, please describe: Please check below the words that best describe your peer relationships: Spontaneous Follower Leader Have Difficulty Making Friends Have Few Friends Have a Lot of Friends Make Friends Easily Have Long-Time Friends Have a Few Good Friends Other (please describe): Please describe your friendships: Culture/Ethnicity To which cultural or ethnic group, if any, do you consider you belong?: Are you experiencing any problems due to cultural or ethnic issues? No Yes If yes, please describe: Is there any other cultural/ethnic information you want your therapist to know? Spiritual/Religious How important are spiritual matters to you? Not at all A little Somewhat Very Are you affiliated with a spiritual or religious group? No Yes If yes, please describe: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 5 of 6
6 Is your family affiliated with a spiritual or religious group? No Yes If yes, please describe: Would you like your spiritual/religious beliefs included in counseling? No Yes If yes, please describe: Internet How much time do you spend on the internet/phone/ipod/video games a day?: hours Does media use interfere with school work? Yes No Job? No Yes Family time? No Yes Friendships? No Yes Extra-curricular activities? No Yes Leisure/Recreational Please describe your family s areas of interests or hobbies that you do together: Please describe your areas of interest or hobbies (e.g., art, books, bowling, church activities, crafts, fishing, hunting outdoor activities, school activities, school clubs, school sports, scouts sports (outside of school), working out, etc.) Activity How often I How often I have participate? participated in the past? Current Employment Status Do you have a job? No Yes Full Time Part Time Where? Do you have any concerns about your work environment? No Yes Please explain: Legal History Do you have a history of legal charges? No Yes If so, please describe Do you have involvement with any of the following people or services? No Yes If yes, please circle all that apply: County Social Worker Probation Officer Adult/Child Protection Guardian Ad Litum If so, please describe: Additional Personal Information Is there any additional information that you believe would help me in understanding you?: Is there any additional information that would help me understand your current concerns or problems?: Is there anything else that you would like me to know about your family?: What are your goals for therapy? Is there anything else that you think would help you to have a positive therapy experience?: Client Signature: Date: Hope in Healing Counseling and Wellness, LLC, Adolescent Psychotherapy Intake (revised ) Page 6 of 6
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