AMY M. JACOBS, LLC
The Therapy Center
7807 E. Funston
Wichita, KS 67207
Phone: (316) 636-1188 Fax: 316-636-1190
CHILD/ADOLESCENT INTAKE INFORMATION FORM
Today’s Date: _________________________
DEMOGRAPHIC INFORMATION:
Name of Child: __________________________________ DOB: ___________________ Age: _______________
Person Completing Form: __________________________________ Relationship to child: ___________________
Parents (Name and Age): Father____________________________ Mother_______________________________
Home Address: ______________________________________________________________________________
If parents share custody/visitation, describe the plan: ___________________________________________________
__________________________________________________________________________________________
Name(s) of stepparents: ____________________________________________________________________
Siblings (Names and Ages) _____________________________________________________________________
__________________________________________________________________________________________
PRESENTING CONCERNS:
What brings you to this appointment today for your child: ______________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How long have you been concerned about this: _______________________________________________________
Describe times when concerns have been better: _______________________________________________________
__________________________________________________________________________________________
Describe times when concerns have been worse: _______________________________________________________
__________________________________________________________________________________________
Has your child been involved in treatment/therapy before for these or other concerns: (circle) YES
NO
If Yes: Name of Provider: __________________________________________________
When? ____________________________ Length of Treatment: ______________
How helpful was this experience: _______________________________________
________________________________________________________________
Intake Information Form-Amy M. Jacobs, LLC
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List any significant events/stressors consider may contribute to current concerns: ______________________________
__________________________________________________________________________________________
MEDICAL HISTORY:
Name of Primary Care Physician/Pediatrician: _______________________________________________________
Address: _________________________________________________________________
List any medical conditions, illnesses, serious injuries, seizures, head trauma, surgeries, hospitalizations your child has
experienced:
__________________________________________________________________________________________
__________________________________________________________________________________________
List any food, drug, or environmental allergies your child has: ____________________________________________
__________________________________________________________________________________________
Current medications prescribed to your child:
Name of Medication
Dosage
Reason
Start Date
Prescriber
List any past medications your child has been prescribed: _______________________________________________
__________________________________________________________________________________________
Any family history of medical/mental problems? (Mark with M-mother’s side, F-father’s side, B-both)
___Heart Disease
___High Blood Pressure
___Stroke
___Dementia ___Anxiety
___ADHD
___Legal Problems
Active
Healthy Picky
Describe your child’s sleep pattern: (circle)
Any history of: (circle)
____Depression
___Cancer
___LungDisease
___Bipolar
___Schizophrenia
___Psychiatric Hospitalizations
Describe your child’s activity level: (circle)
Describe your child’s appetite: (circle)
___Diabetes
Energetic
Sluggish
Excessive
Difficult to fall asleep
Restless
Difficult to awaken in the morning
Nightmares
Underactive
Poor
Normal
Night terrors
Intake Information Form-Amy M. Jacobs, LLC
___Other___________________
Sleep walking
Awakens in the night
Sleep talking
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DEVELOPMENTAL HISTORY:
Describe pregnancy with your child: _______________________________________________________________
Describe delivery (any complications?):_____________________________________________________________
How did your child meet developmental milestones? (Rate as: N-normal, E-early, L-late):
Sitting Up_______
Crawling_________
Standing Up ___________ Walking__________
Talking________
Toilet training_________
Describe any concerns regarding your child’s development: _________________________________________
___________________________________________________________________________________
Describe your child’s temperament as an infant: (circle those that apply) Active
Easy to Soothe
Tense
Difficult to Soothe
Reactive to Touch
Slow to Warm up
Poor Eye Contact
Alert
Colicky/Fussy
Withdrawn
Calm
Cuddler
Separation Anxiety
EDUCATION:
Name of School your child attends: _______________________________Location:___________Grade:_________
Teacher: ______________________Counselor: ____________________ Principal: ___________________
Has your child had testing done through the school: Yes No
If yes, did child qualify for specialized services through an IEP? Yes No
or a 504 Plan: Yes or No
Specialized services for: ____________________________________________________________
List any concerns/difficulties with your child and school: _______________________________________________
__________________________________________________________________________________________
ADDITIONAL INFORMATION: Please share any additional information you consider is important for me to know:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
THANK YOU AND I LOOK FORWARD TO MEETING YOU AND YOUR CHILD. Amy Jacobs, MS, LCP
Intake Information Form-Amy M. Jacobs, LLC
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