High School/ Middle School Initial Intake Form

Today's Date*

Client Name (name of the adolescent)*

First Last

Date of Birth*

Sex*

Client's Phone (if different from parent phone number)

Client's Address

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

Counselor you are scheduled with*

Responsible Party's Name*

First Last

Relationship to Client*

Phone*

Email*

2nd Responsible Party's Name

First Last

Relationship to Client

2nd Responsible Party's Phone

2nd Responsible Party's Email

Why are you seeking counseling?*

Please describe the impact of your struggles on family and friends.

Please check any stressors in the past year:*

Define your other*

Please check any current challenges.*

Please check any current challenges.

If you said, other, please define*

3 strengths you have:*

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

Have you had similar and significant symptoms in the past?*

When?*

Did they recently increase?*

If yes, when, and what caused it?*

Prior Psychiatric Hospitalizations?*

If yes, when and for what reason?*

Past Counseling History?*

Please list therapist, reason, and number of times seen.*

Was it a positive/useful experience?*

Substance Abuse History?*

List what substances and when started*

List treatment Locations and Dates:*

Have you experienced any physical, sexual, or emotional abuse?*

Please list:*

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

Please list:*

Have you ever attempted suicide?*

Please explain:*

Have you ever been hospitalized for attempted suicide?*

Do you have a history of self-harm?*

Are you currently self-harming?*

What is your height?*

What is your weight?*

Are you currently physically healthy?*

Please explain:*

List any medications you are currently taking, why, date prescribed, and any side effects/reactions.*

Have you or any of your 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:*

Are you currently in school?*

Name of School*

What grade are you in right now?*

Please enter a number from 6 to 12.

Are you receiving any special education services (IEP plan, 504 plan)?*

Please explain:*

How would you describe your 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 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)

Are you dieting?*

How many meals do you eat in an average day?*

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

What is your height and weight?*

Which forms of Caffeine do you consume?*

How many cups/cans per day?*

Are you sexually active?

Any discomfort or dysfunction with intercourse?

Frequency?

Any Concerns?

Is there anything you want me to know about your sexuality?*

Is there anything else you want me to know?*

How do you identify spiritually/religiously? (i.e., Christian, atheist, Hindu, etc...)?*

Would you say you have a personal relationship with Jesus Christ?*

For how long?*

Do you attend a church?*

Which church? And how often?*

Do you pray and/or meditate?*

If so, how often?*

Do you read/study the Bible?*

If so, how often?*

Do you have personal concerns or questions related to God, the Christian faith, and/or the church?*

Are you open to discussing relevant matters of faith with your therapist?*

Are your parents currently married?*

If there is shared custody, please describe the arrangement:

Please list for each of your siblings the following: Name, Sex, Date of Birth, Age, and relevant notes.

Please describe any important family events that may have had an impact on your 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: This is a list of things different people might say about themselves. We are interested in how you would describe yourself. There are no right or wrong answers. So you can describe yourself as honestly as possible, we will keep your response confidential. We’d like you to take your time and read each statement carefully, selecting the response that best describes you.

People would describe me as reckless.*

I feel like I act totally on impulse.*

Even though I know better, I can’t stop making rash decisions.*

I often feel like nothing I do really matters.*

Others see me as irresponsible.*

I’m not good at planning ahead.*

My thoughts often don’t make sense to others.*

I worry about almost everything.*

I get emotional easily, often for very little.*

I fear being alone in life more than anything else.*

I get stuck on one way of doing things, even when it’s clear it won’t work.*

I have seen things that weren’t really there.*

I steer clear of romantic relationships.*

I’m not interested in making friends.*

I get irritated easily by all sorts of things.*

I don’t like to get too close to people.*

It’s no big deal if I hurt other peoples’ feelings.*

I rarely get enthusiastic about anything.*

I crave attention.*

I often have to deal with people who are less important than me.*

I often have thoughts that make sense to me but that other people say are strange.*

I use people to get what I want.*

I often “zone out” and then suddenly come to and realize that a lot of time has passed.*

Things around me often feel unreal, or more real than usual.*

It is easy for me to take advantage of others.*

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High School/ Middle School Initial Intake Form

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5236 Strauss Cabin Rd, Fort Collins, CO 80528
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