Child Intake Form

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e.g. type in Mar 3 2011

Child's Information
Parent 1 Information
Parent 2 Information
Parent Consent and History
Family Information

Siblings

Name Age

Step Siblings

Name Age

Who lives with the child at each parent's house?

Parent 1's House

Name Relationship to Child

Parent 2's House

Name Relationship to Child
Emergency Contact Information
Physical Health Information

Please list all medications that your child presently takes

Medication What is it Used For? Dosage
Family History

Have any of your child's biological relatives on either parent's side of the family had any of the following:

Condition or Event Relationship to Child
Anxiety
Panic Attacks
Depression
Obsessive-compulsive disorder
Bipolar disorder
Death from suicide
Alcohol or drug problems
Police record (arrests, jail)
Schizophrenia
Developmental delays
Autism/ Asperger's
Learning disorder
Attention problems (ADHD)
Tourette's or other tic problems
Other (please describe)
Pregnancy History
Delivery History

Early Years

Sleep Hygiene
School/Academic History
General Review
What are your top three concerns about your child?
Name of Professional Agency Date of Service