Youth Intake Form ~ CCD

Welcome & thank you for choosing me to be your Counselor/Therapist!!! As a representative of The Center for Child Development, I promise to work side by side with you & your child, providing you with quality care & attention, & family centered services that will assist your child in making the desired transition into the next phase of their life. Please note that the Policies & Privacy Practices for TC applies to me, your Counselor/Therapist & the services that I provide.

Tomaro Pilgrim ~ The Center for Child Development
Youth Intake Form ~ Complete, Sign & Submit
(Must be completed prior to initial meeting!)

Contact Information

* Indicates required field

Child's Name *

First

Last

Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of birth *

Gender *

Parent's email *

Is the child in school or employed? *

School Employed Both

If employed, where and for how long? *

Guardian's name *

First

Last

Relationship to child *

Guardian's address if different *

Line 1

Line 2

City

State

Zip Code

Country

Guardian's contact number *

Is this a cell phone? *

Yes No

If so, can we text? *

Yes No

Can we leave a message? *

Yes No

Guardian's email *

Name of person financially responsible for child if different from Gaurdian *

Contact for responsible party *

Occupation of responsible party *

Yearly Income *

Name of emergency contact *

First

Last

Emergency contact's phone number *

Relationship to child *

Child/Adolescent Questionnaire

Please review the questions below; reflect on the past 2 weeks and complete them to the best of your ability. The information collected will assist your child's counselor/coach in creating a plan that will assist them in your goals. Please take note that there are two sides to the form. If your child is under 12 years of age please complete the 'child' side of the form; if the child is 12 and over please complete the adolescent side of the form.

Presenting Problems/Concerns

Why is the child in need of counseling/coaching services? *

If you chose other, please explain. *

Are the child's issues affecting any of the following?

Has the child ever had thoughts, made statements or attempted to hurt yourself? *

Yes No

If yes, please explain. *

Has the child ever thoughts, made statements or attempted to hurt someone else? *

Yes No

If yes, please explain. *

Has the child ever been physically hurt or threatened by someone else? *

Yes No

If yes, please explain. *

Family & Developmental History

Please briefly describe quality of relationship to each checked. *

Please briefly explain any mental health issues within the family. *

Any additional information about family mental health please explain. *

Medical History

Were there any complications during pregnancy? *

Yes No Don't know

If you answered yes or don't know please explain. *

Did the biological mother use any tobacco, medication, street drugs or alcohol while pregnant with this child? *

Yes No Don't know

Did the child have any developmental delays in early childhood (walking, crawling, talking, toileting, etc.)? *

Yes No Don't know

If you chose yes or don't know, please explain. *

Did the child have any childhood illnesses, surgeries, brain injury, etc.? *

Yes No Don't know

If you chose yes or don't know, please explain. *

Is the child on medication? *

Yes No

If yes, please provide the name of medication, dosage and purpose. *

Is the child allergic to anything? *

Yes No Don't know

If you chose yes or don't know, please explain. *

ANY outpatient care? *

Yes No

When? *

Provider/Program? *

Reason? *

ANY inpatient care? *

Yes No

When? *

Facility? *

Reason? *

Drug/Alcohol treatment? *

Yes No

When *

Facility? *

Reason? *

Self-help/Support groups? *

Yes No

When? *

Group/Program *

Reason? *

Substance Use History

Does the child have a history, or has he/she used any illegal substances in the last 90 days? *

Yes No Unsure

If you answered yes to the above question then please answer the questions below, otherwise proceed to the next section of the intake form.

Has the child had withdrawal symptoms from trying to stop using any substance? *

Yes No Don't know

If you chose yes or don't know, please explain. *

Has the child ever had problems with school, relationships, health, the law, etc. due to substance abuse? *

Yes No Don't know

If you chose yes or don't know, please explain. *

Education

Is the child currently in school? *

Yes No

If you answered yes to the question above, please answer the following questions; otherwise please proceed to the next section.

Name and location of School? *

Last grade completed? *

Interpersonal/Social/Cultural Information

Please describe child' strengths, skills & talents. *

Please describe any hobbies or interests (reading, art, etc.). *

What changes would you like to see in the child? *

Is the child currently the subject of a custody case? *

Yes No

Has the child ever been a ward of the court with Child Protective Services as guardian? *

Yes No

Does the child have any legal offenses on record or pending in court? *

Yes No

If you selected yes on any of the questions above, please explain. *

How did you hear about us? *

I have answered all of the questions listed on this form truthfully, to the best of my knowledge. *

Please check here to confirm.

I have answered all of the questions listed on this form truthfully, to the best of my knowledge. *

Please click below in order to submit your Intake Form. You will be forwarded to the appointment page!

SUBMIT ~ I CONFIRM THAT I HAVE READ THE POLICIES & SERVICES, & AGREE TO SERVICES PROVIDED BY TOMARO PILGRIM

POLICIES & PRIVACY PRACTICES

YOUR CART

Tomaro Pilgrim ~ The Center for Child Development
Youth Intake Form ~ Complete, Sign & Submit
(Must be completed prior to initial meeting!)

Contact Information

Child/Adolescent Questionnaire

Presenting Problems/Concerns

CHILD ~ Under Age 12

ADOLESCENT ~ 12 years and older

Family & Developmental History

Medical History

Substance Use History

Education

Interpersonal/Social/Cultural Information

Please click below in order to submit your Intake Form. You will be forwarded to the appointment page!

YOUR CART

Tomaro Pilgrim ~ The Center for Child DevelopmentYouth Intake Form ~ Complete, Sign & Submit​(Must be completed prior to initial meeting!)

Contact Information

Child/Adolescent Questionnaire

Presenting Problems/Concerns

CHILD ~ Under Age 12

ADOLESCENT ~ 12 years and older

​Family & Developmental History

Medical History

Substance Use History

Education

Interpersonal/Social/Cultural Information

​​Please click below in order to submit your Intake Form. You will be forwarded to the appointment page!​

Tomaro Pilgrim ~ The Center for Child Development
Youth Intake Form ~ Complete, Sign & Submit
(Must be completed prior to initial meeting!)

Family & Developmental History

Please click below in order to submit your Intake Form. You will be forwarded to the appointment page!