Elementary/Preschool Initial Intake Form

Today's Date*

Child's Name (1)*

First Last

Date of Birth*

Sex*

Child's Name (2)

First Last

Date of Birth

Sex

Child's Name (3)

First Last

Date of Birth

Sex

Child(ren)'s Primary Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Counselor you will be seeing*

Responsible Party's Name*

First Last

Relationship to Client*

Phone Number*

Email*

2nd Responsible Party's Name*

First Last

2nd Responsible Party's Email

Relationship to Client

2nd Responsible Party's Phone Number

Why are you seeking counseling for your child?*

Please describe the impact of the child's struggles on family and friends.

Please check any boxes for stressors for your child in the past year*

Define your other*

Please check any current challenges.*

If you said, other, please define*

3 strengths your child has:*

List the 3 greatest struggles for your child and your family in regard to how therapy can help.*

Has your child had similar and significant symptoms in the past?*

When?*

Did they recently increase?*

When, and what caused it?*

Prior Psychiatric Hospitalizations?*

When and for what reason?*

Past Counseling History for your child?*

How many times was your child seen by the therapist?*

Was it a positive/useful experience?*

Substance Abuse History?*

List what substances and when started*

List treatment Locations and Dates:*

Has your child experienced any physical, sexual, verbal, or emotional abuse?*

Please list:*

Any head/brain trauma? (concussion, asphyxia, other injury)*

Please list:*

Has your child ever attempted suicide?*

Please explain:*

Has your child ever been hospitalized for attempted suicide?*

Does your child have a history of self-harm?*

Is your child currently self-harming?*

What is your child's height?*

What is your child's weight?*

Is your child currently physically healthy?*

Please explain:*

List any medications your child is currently taking, why, date prescribed, and any side effects/reactions.*

Has your child or any of your child’s relatives suffered from major issues (i.e. cancer or diabetes) or mental health issues (depression, bipolar, substance abuse, etc.)?*

Family Physician*

First Last

Family Physician Phone Number*

Month and year of last physical

Significant Allergies:*

Is your child currently in school?*

Name of School your child attends:*

What grade is your child in right now?*

Please enter a number from 0 to 5.

0 = Preschool

Is your child receiving any special education services (IEP plan, 504 plan)?*

Please explain:*

Has your child had any behavioral struggles at school?*

Please explain:*

How would you describe your child's exercise?*

Sedentary (No Exercise)
Mild exercise (i.e., climb stairs, walk 3 blocks, golf)
Occasional vigorous exercise (i.e., work or recreation, less than 4x/week for 30 min.)
Regular vigorous exercise (i.e., work or recreation 4-5x/week for 30-50 minutes)
Regular vigorous exercise (i.e., work or recreation 5-7x/week for 50+ minutes)

How would you describe your child's sleep?*

Insomnia (no consistent or sound sleep)
Little Sleep (i.e., 2-4 hours per day)
Limited Sleep (i.e., 4-6 hours per day.)
Regular Sleep (7 hours or more per day on average)

Is your child dieting?*

How many meals does your child eat in an average day?*

Do you have concerns about your child's eating patterns or habits?*

Which forms of Caffeine does your child consume?*

How many cups/cans per day?*

How does your child identify spiritually/religiously? (i.e., Christian, atheist, Hindu, etc...):*

Would you say your child has a personal relationship with Jesus Christ?*

For how long?*

Does your child attend a church?*

Which church? And how often?*

Does your child have personal concerns or questions related to God, the Christian faith, and/or the church?*

Is your child open to discussing relevant matters of faith with your therapist?*

Are the child’s parents currently married?*

If there is shared custody, please describe the arrangement:*

Please list for each sibling the following: name, date of birth, age, sex, and relevant notes.*

Please describe any important family events that may have had an impact on your child’s issues (i.e. divorces, custody changes, moves, etc.).*

Please describe any cultural factors (family beliefs, and values, religion, ethnicity, language, etc.) that are important to your family.*

Other Relevant Notes:

Instructions to Parent or Guardian: The Following Questions ask about the early development and early and current home experiences of your child. Some questions require that you think as far back as to the birth of your child. Your response to these questions will help your child’s clinician better understand and care for your child. Answer each question to the best of your knowledge or memory.

What is your relationship to the child receiving care?*

Was he/she born before he/she was due (premature)?*

Were the doctors worried about his/her medical condition immediately after he/she was born?*

Did he/she have to spend any time in a neonatal intensive care unit (NICU)?*

Could he/she walk on his/her own by the age of 18 months?*

Has he/she ever had a seizure?*

Did he/she ever lose consciousness for more than a few minutes after an accident?*

By the time he/she was age 2, could he/she put several words together when speaking?*

Could people who didn’t know him/her understand his/her speech by the time he/she reached age 4?*

Have you ever been concerned about his/her hearing or eyesight?*

By the time he/she was age 4, was he/she interested in playing with or being with other children?*

Was there ever a time when he/she could not live at home and someone else had to look after him/her?*

Has he/she ever been admitted to the hospital for a serious illness?*

Does anyone at home suffer from a serious health problem?*

Does anyone at home have a problem with depression?*

Does anyone at home regularly see a counselor, therapist, or other mental health professional?*

Does anyone at home have a problem with alcohol, drugs, or other substances?*

Would you say that the atmosphere at home is usually pretty calm?*

How often are there fights or arguments between people at home?*

How often does your child get criticized to his/her face by other family members when he/she is at home?*

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Elementary/Preschool Initial Intake Form

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