@mainstcounselingsolutions

Intake Form

Client First & Last Name

Client Birthday & Age

Client Address

Parent 1 First & Last Name

Parent 1 Email Address

Parent 2 First & Last Name

Parent 2 Email Address

Parent 1 Relationship to Client

Biological

Adoptive

Step

Others

Parent's Marital Status

Married

Separated

Divorced

Parent 1 Phone Number

Parent 1 Address (If Different)

Parent 2 Phone Number

Parent 2 Address (If Differnet)

Parent 2 Relationship to Client

Biological

Adoptive

Step

Other

If separated or divorced, please explain custody agreement

Family Members Living in the Home

Family Member 1

Family Member 2

Family Member 3

Family Member 4

Any Other Family Members

Providers

Pediatrician

Past Therapist(s)

Other Providers (psychiatrist, speech therapist, etc.)

Reason for Seeking Treatment

Primary Reason for Seeking Treatment

History of Problems

Past/Current Treatment

Developmental History

Date Mother Started Prenatal Care

Please List Any Difficulties or Complications Biological Mother Experienced During Pregnancy?

Where any of the below used during the pregnancy

Smoked Tobacco

Smoked Marijuana

Drank Alcohol

Used Any Other Drug (cocaine etc.)

None

Wher any medications used during the pregnancy?

Labor & Delivery (length of pregnancy, type of birth, complocations during delivery, etc.)

Baby's Weight & Length

APGAR Scores at Delivery

Please List Any Newborn Complications

As an infant, was there anything unusual or difficult about this child within the first 12 months of life?

Describe your child's personality as a baby?

Please Select Any Developmental Milestones That Your Child Met

Make eye contact

Track objects

Smile responsively

Sit up

Crawl

Roll over

Walk

Say first word

Speak in sentences

Self feed with utensils

Drink from a cup

Play with others interactively

Dry daytime

Dry nightime

Dress self

Rides a bicycle

Tie Shoes

Please check any problems your child had/has as an infant or young child?

Seperation problems

Language problems

Development/Growth problems

Rocking or hand flapping

Speech impediment

Repetitive language/movements

Unresponsive to questions

Used incorrect promouns to refer to self/others

Never or rarely began a conversation

Talks to self and not others

Restless or overactive

Attention problems

Aggression

Does not listen to rule following

None

Please list any milestones that your child did not meet or was delayed.

Please list any checked problems

Please list any sensory problems your child had/has

Does your child have/had any problems with sleep or appetite?

Had/Does your child have any problems with transitions, adapting to new environments, and/or seperation issues?

Did your child ever recieve speech or occupational therapy? If so for what and how long?

Medical History

My child's immunizations are up to date

Child ever been hospitalized? When? Why? Length & Treatment?

Any history of serious injury?

Any history of surgery? When? Why?

Does your child have any allergies? Have they ever had a life threatening allergic reaction(s)?

has your child experienced any medical isses? (headaches, heart problems, dizziness, infections, seizures?)

History of medications. Please include why they were prescribed and length of prescription

Please list any current medications your child is taking

Has your child tried or currently use alcohol, tobacco, marijuana, or any illegal substances? Please indicate substance, when used, frequency of usage, and if they have stopped.

Does your child have any trouble at school or at home with the law? Please explain (because of substance use? behavior?)

Does your child have any history of ear infections or hearing problems?

Date of last hearing screening

Does your child have any history of vision problems or vision therapy?

Date of last vision screeing

Females

Age of first menstrual period. Is it regular? Any difficulties related to menstrual period?

Social History

Describe child's relationships with parents or caregivers (past and current)

Describe child's relationship(s) with siblings (past and current)

Describe your child's current peer relationships

What are your child's strengths & weaknesses?

What does your child like and dislike about themselves?

Has your child been picked on, teased or bullied? Has your child picked on, teased or bullied others?

How does your child respond to peer pressure?

Does your child have or have they had a significant other?

List your child's interest, hobbies, sports, etc.

History of legal or police involvement with child/anything child would be aware of or impacted by?

Any history of abuse (sexual, physical, emotional)

Academic History

At what age and where did your child begin school?

Current Grade

Current School

Is your child receiving special education services? If yes, explain the accommodations. Has your child ever repeated a grade?

Does your child refuse to go to school?

Has your child been suspended or expelled from school?

What is your child's best and most challenging school subjects?

Has your child had any educational or psychological testing done?

Family History

Please describe any family members medical illnesses

Please describe any family history of mental illness

Thanks for submitting!