Minor Intake FormPlease complete on behalf of your child. Name of person completing this form: * First Name Last Name Your relation to the child: * Phone * (###) ### #### Name of other parent/legal guardian: Phone (###) ### #### Child’s first name: Child's Birth Date: MM DD YYYY Child's Ethnicity: Child's Religion: Child's Sex / Gender: Child's Address: Address 1 Address 2 City State/Province Zip/Postal Code Country Who does your child live with? ACADEMIC INFORMATION Name of child's school: Child's grade/year in school: School program: What are your child's typical grades? How did you find this therapist? Word of mouth I'm a former client Order of Psychologists (OPQ) Psychology today Rate MDs CJAD 800 Google Other Kindly specify if you checked other What are the reasons for your child's visit? How intense is your child's emotional distress on a level from 1 (mild) to 10 (severe)? Please Explain. Overall, how much do the problems affect your child’s ability to perform in school, get along with others, and perform daily tasks such as chores? Please rate on a scale of 1 (midly disruptive) to 10 (incapacatating), and describe. When did these problems start? What was going on in your child’s life at that time? PSYCHIATRIC AND MEDICAL HISTORY Please list any psychiatric or “mental” problems your child has been diagnosed with: Please list any medical or “physical” problems that your child has been diagnosed with: Please list any medications your child currently takes, and what they are taken for: Name of family doctor: Phone (###) ### #### When was your child's last checkup? MM DD YYYY What were the results? Name of Psychiatrist: Phone (###) ### #### When was their last appointment? MM DD YYYY What were the results? MENTAL HEALTH TREATMENT HISTORY Has your child ever been hospitalized for psychological or psychiatric reasons? No Yes If yes, please describe when, where, and for what reason Please tell us about any other mental health professionals your child has consulted with in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment): CURRENT HABITS Please describe your child’s current habits in each of the following areas: Smoking, Drinking, Drug Use, TV Use, Internet Use, Video game Use, Caffeine Intake, Exercise, Eating, Sleeping, Fun and Relaxation, Chores and Responsibility. RELATIONSHIPS Please describe your child’s relationships with each of the following people, if applicable: Biological Mother, Biological Father, Step-Parents, Legal Guardians, Siblings, Extended Family, Your Children, Friends, Romantic Partner(s), Colleagues, Classmates, Total number of close supportive relationships: STRESSFUL LIFE EVENTS Please check any significant or stressful life events that your child has been experiencing: A recent move or change in school Abuse or neglect Bullied or ignored by peers Academic difficulties Weight control issues Sexual orientation concerns Self-injury Death or illness of a loved one or pet Family conflict Separation or divorce Other If you checked to any of the above, please describe more about it below: What are your child’s positive qualities and skills? What do you like about yourchild? What qualities have helped your child to succeed at overcoming difficulties in the past? Please tell us about your child’s interests (sports, hobbies, talents, etc.) Does your child agree that the problem that she or he is seeking help for is problematic? What are some goals for your child’s therapy? What would you like him/her to achieve by attending therapy? What concerns do you have about your child attending therapy or working on these problems? Is there anything else that you would like to mention? Client Approval (Client’s Parent/Guardian if under 18): * I understand this is a legal representation of my approval I approve I disapprove Date * MM DD YYYY Thank you!
