Parent Intake Form

GENERAL
Name (required): Date of birth
Address:
City: State: ZIP:
Home phone: May I leave a message? YesNo
Work/Cell phone: May I leave a message? YesNo
Email: May I contact you via email? YesNo
Occupation/studying
Emergency contact: Phone: Relationship:
Educational background:
Nationality/religion (if any):
Significant partner status (please select):
SingleEngagedMarriedDivorcedSeparatedLiving togetherRemarriedWidowedOther


TREATMENT INFORMATION
Reason for seeking counseling/therapy at this time:
What you would like to be different in your life when you are done with therapy? What do you hope to achieve with therapy?

Please check any of the following major stressors in the past year or so that may pertain to your family:
Death of a Close FriendDeath of a Family Member
Major Illness in FamilyNew Addition to Family
Divorce/SeparationMarital Stress
Family Finances

Has your child ever been seen by another counselor (context; timeframe; outcome):


FAMILY HISTORY
Who are the primary people in your child’s life? Include quality of relationship with each.
Is there anything important in your child’s past medical or personal history that might be relevant to counseling?

Is your child taking any sort of medication, and if so, for what reason?

Has your child ever threatened, considered or attempted suicide? YesNo
If yes, please explain:

Have s/he ever been in a drug, alcohol or other treatment program? YesNo
If yes, please provide details:

Does s/he currently drink alcohol? YesNo
How much/how often:
Does s/hecurrently use recreational drugs? YesNo
How much/how often:

Please check any of the following struggles that pertain to you:
AnxietySexual/Gender ProblemsImpulse-ControlThought Patterns
DepressionSuicidal ThoughtsDrug/Alcohol UseUnhappiness
Health ProblemsFears/PhobiasFamily Stress
InsomniaCutting/Self-MutilationEating Disorders
Relationship ProblemsAngerAcademic Challenges

Please check any of the following struggles that pertain to your child:
AnxietySexual/Gender ProblemsImpulse-ControlThought Patterns
DepressionSuicidal ThoughtsDrug/Alcohol UseUnhappiness
Health ProblemsFears/PhobiasFamily Stress
InsomniaCutting/Self-MutilationEating Disorders
Relationship ProblemsAngerAcademic Challenges

Do you or any of your relatives have a history of mental illness? YesNo
If yes, please explain:


FAMILY INFORMATION
Child's parents and step-parents (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Child's siblings and step-siblings
First Name Age Gender
First Name Age Gender
First Name Age Gender
First Name Age Gender

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