Family Counseling Intake Form

Child/Adolescent
Client #____________
Client Name____________________________
Date_______________
Preferred Name____________
Marital Status_______________
Date of Birth________________
Gender________________
Race____________
Ethnicity______________
Address_________________________________________________________________________________________________________
Contact Information (please circle preferences for appointment reminders)
Home__________________________ Cell___________________________ Work_____________________________
Email____________________________________________________________________________________________________
Please check all problems that you are seeking counseling for:
Anxiety

Family Conflict

Trauma

Physical/Medical Problems

Depression
Childhood Trauma

Attention/Concentration Difficulties

Child/Adolescent Behavior Problems

Developmental Concerns

Difficulty with Social Interactions

Grief

Occupational Problems

School/Academic Problem
Stress

Substance Abuse
Eating Disorder

Verbal/Physical Aggression
Spouse/Partner Conflict

Parenting Problems
Other:
Please provide brief description of any checked problems
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These questions are for the client, however, please let your therapist know privately if you would
answer yes to any of these questions.
Have you wished you were dead or wished you would go to sleep and not wake up?
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Have you actually had any thoughts of killing yourself?
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Have you ever done anything, started to do anything, or prepared to do anything to end
your life? If yes, how long ago did you do any of these
things?_________________________________________________________________________________________________
Has the client previously received any mental health services? If yes, please list
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Approved 04/27/2015

Family Counseling Intake Form

Child/Adolescent
Client #____________

Are you aware of any complications with clients pregnancy and birth? If yes, please describe
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When did client achieve the following developmental milestones?
Milestone
Age
Sitting up
Turning over
Talking
Crawling
Walking
Potty trained

Who is the clients primary doctor/pediatrician?

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Does the client have any current medical conditions? If yes, please list
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Does the client have any allergies? If yes, please list
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Has the client ever been hospitalized overnight for medical reasons? If yes, please list
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Past and Current medications
Name

Approved 04/27/2015

Dosage

Frequency

Prescription
Over the counter

Prescribing
doctor

Reason for taking

Family Counseling Intake Form

Child/Adolescent
Client #____________
School History

Current School
Name:
School
Address:
School Phone:
Kindergarten
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade

School
Fax

Schools Attended

Present
Grade:
Teacher
Name:
School
Nurse:

Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh Grade
Twelfth Grade
Other

Has the client ever received special education services? If yes, Please explain:
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Describe the clients grades throughout school career
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Describe the clients conduct throughout school career
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Describe the clients school attendance
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Has the client ever been suspended or expelled? If yes, please explain
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Approved 04/27/2015

Family Counseling Intake Form

Child/Adolescent
Client #____________
Substance Abuse History
These questions are for the client; however, please let your therapist know privately if you would
answer yes to the last question.

Do you use Alcohol? How often/much

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Do you use tobacco? What type? How often/much?
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Have you ever used illegal substances? What type? How often/much?
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Have you ever received substance abuse treatment? If yes, please explain
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Do you consider your substance use to be a problem? If yes, please explain
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Approved 04/27/2015