Child and Adolescent In-Take
Child Identifying Information
Name:
Date: ___/___/___
Ethnicity/National Origin:
Gender:  Male
Age:
Birthdate:___/___/___
Birth Place:
Child’s School:
Grade:
Parent Identifying Information
Father’s Name:
Father’s Address:
Phone:
Place of Business:
Occupation:
Mother’s Name:
Mother’s Address:
Phone:
Place of Business:
Occupation:
Household Information
Child Lives With:
If parents are divorced are separated, how old was child at the time?:
If natural parents are deceased, how old was child at the time?:
How did the child react to either of the above?:
Are languages other than English regularly spoken in the child’s household?:  Yes
Has the family moved during the child’s life?:  Yes  No
From:
To:
 No
What language(s)?:
Please list:
Child’s Age
Grade
 Female
List the name(s) of the child’s brother(s) and sister(s):
Brothers’ Name:
Age:
Grade:
Step/Half:
Sisters’ Name:
Grade:
Step/Half:
Age:
Who is the child closest to:
List below others who live with the family or who have lived with the family during the child’s lifetime:
Name:
Age:
Relationship:
Social Adjustment of Child
Describe the child’s relationship with mother and father:
Does the child have behavior issues at home?:
Is the child more or less of a problem than brother(s) or sister(s)?
 More
 Less
Check the items below which describe disciplining of child:
 Strict
 More strict than that used with other siblings
 Lenient
 More lenient than that used with other siblings
Generally, how does the child respond to discipline?:
Does the child participate in any children’s groups?  Yes  No
 Brownies or Cub Scouts
 Religious Groups
 Scouts
 Community Activities
 4-H
 Other
 Sports (List:
)
Check the child’s present major interests:
 Listening to radio or iPod
 Watching television
 Books or magazines
 Collecting things
 Internet or computer
 Taking care of pets
 Other (List:
 Telling stories/jokes
 Building or making things
 Drawing or coloring pictures
 Playing video games
 Playing by him/herself
 Playing with others
)
On the basis of your observation, check any of the following which best describe your child:
 Talks constantly
 Dislikes meals
 Active
 Curious
 Easily upset
 Easily discouraged
 Healthy
 Good humored
 Selfish
 Slow of movement
 Patient
 Learns slowly
 Seldom completes a task
 Helps at home
 Not much help at home
 Imaginative
 Learns easily
 Finishes tasks
 Upset by criticism
 Takes criticism
 Enjoys his/her meals
 Feels inferior
 Prone to fight with playmates
 Easily injured
 Shows concern over his/her personal safety
 Restless, overactive
 Never talks to others
 Gets along with playmates
 Looks forward to going to school
 Talks only when necessary
 Resists going to bed
 Dreads going to school
 Aggressive, hostile
 Wants his/her own way
 Cannot control temper
 Can dress and care for him/herself
 Lacks self confidence
Has child attended any sort of camp or spent vacations away from parents?:
 Yes
Describe the child’s behavior:
What hobbies has the child had?:
What are his/her favorite TV programs?:
Health History
Were there complications with pregnancy?:  Yes
Were there complications with birth?:
 Yes
 No
Explain:
 No
Explain:
During infancy did child experience any of the following?:
 Allergies
 Difficulty in digesting solid food
 Frequent crying
 Poor sleep habits
 No
At any stage has the child appeared awkward, clumsy, or otherwise uncoordinated?:
Which hand does the child prefer?:
 Right
 Yes
 No
Explain:
 Left
List any childhood diseases and serious injuries the child received and ages at which these occurred:
Disease/injuries:
Age:
 Yes
Does child have any physical disabilities that might interfere with his/her learning, playing, etc?
 No
Explain:
Does child have any difficulty in speaking (such as mispronouncing words, stuttering, etc.)?:
 Yes
 No
Explain:
Does child have any hearing difficulties?:
 Yes  No
Does child have a vision problem?:  Yes
 No
Check any of the following experiences of your child now or in the past:
 Upset stomach
 Seizures
 Nightmares
 Bed wetting
 Other (List:
)
List any medications the child is taking:
List any previous counseling your child has received:
School History
Pre-school?:
 Yes
 No
Has child changed schools frequently? :
Kindergarten?:
 Yes
 Yes
 No
Has child been absent from school for long periods?:  Yes
 No
Age when entered 1st grade:
In what grades?:
 No
In what grades?:
Reasons:
 Yes
 No
Any problems in reading?:  Yes
 No
Explain:
 Yes
 No
Explain:
Failed any grades?:
Any problems in math?:
Which grades?:
Describe your child’s attitude toward school:
What school activities does your child like the most?:
What school activities does your child like the least?:
Does he/she enjoy reading?:
 Yes
 No
What types of books does he/she read?:
General Information
Describe any major difficulties the child is having now:
At home:
At school:
With other children:
When were you aware that the child difficulties?:
Other comments:
Intake Completed By: ___________________________________ Date: ____________