Youth Intake Form

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 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

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 had 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. *

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. *

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

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

Interpersonal/Social/Cultural Information

Please describe child' strengths, skills & talents. *

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

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

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. *

YOUR CART