Teen Intake Form

Name (required): Date of birth
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
Emergency contact: Phone: Relationship:
Learning disabilities:
Nationality/religion (if relevant):
Who lives in your home with you? (kin, quality of relationship, names, ages):

Reason for coming in for 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 you and/or your family:
Death of a Close FriendDeath of a Family Member
Major Illness in FamilyNew Addition to Family
Parents' Divorce or SeparationFamily FinancesAcademic Struggles
Peer or Social PressuresOther Personal Struggles

Your perception of current marital satisfaction of parents:

General health:
Physician’s name: Telephone:
Reason for medication:
Have you ever been hospitalized for a physical illness? YesNo

Previous therapy/counseling: YesNo
If yes, describe reason, duration and outcome:

What do you consider your strengths as a person?

What do you consider your areas of challenge as a person?

Have you ever considered or attempted suicide? YesNo
If yes, please explain:

Do you currently drink alcohol? YesNo
How much/how often:
Do you currently use recreational drugs? YesNo
How much/how often:
Do you feel you have a problem with alcohol or drugs? YesNo
Are you sexually active? If so, do you feel you understand how to keep yourself safe? Would you like to know more?

Have you ever been physically or sexually violated by a peer or adult in your life? If yes, did you share what happened with an adult? Outcome?

What are some activities you enjoy outside of class time:

Have you noticed a change in work habits, motivation, interest? Please explain:

Number of hours per a day on computer, ipad, itouch, etc.?:

Number of hours per a day texting:

How well do you sleep? How many hours do you get each night?

How much time do you spend alone? By choice or circumstance?

Is there anything else that you feel it would be important for me to know?

Please check any of the following struggles that pertain to you:
General AnxietyWorries about the FutureSelf-ControlSchool Stress
DepressionSuicidal ThoughtsDrug/Alcohol UseUnhappinessPast Trauma
Health ProblemsFears/PhobiasParental Marital Stress
InsomniaCutting/Self-MutilationEating Disorders
RelationshipsAngerReligious ConcernsThought Patterns

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

Siblings and step-siblings (indicate under “age” if deceased)
First Name Age Gender
First Name Age Gender
First Name Age Gender
First Name Age Gender

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