Journey Well, LLC
Intake Questionnaire (Child / Adolescent)
Client Name:
Today’s Date:
PRESENT CONCERN(S)
Please describe the concern(s) for which you are seeking services for your child/adolescent.
(For example, sadness, suicidal thoughts, nervousness, struggles related to loss or trauma, substances, risky behavior, etc.)
Please describe the ways this has been impacting the quality of your child/adolescent’s daily life.
(For example, is it affecting her / his appetite, sleep patterns, school functioning, relationships, legal problems, etc.)
How long has this been problematic for her / him? (For example, “since age 8” or “the past 3 months”.)
What, if anything, have other people in his / her life noticed about what he / she is experiencing?
(Please identify the person’s relationship to your child/adolescent and what they have said.)
What are your desired outcomes for the services your child/adolescent receives at Journey Well, LLC?
JW Intake Questionnaire (Child / Adolescent)
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Journey Well, LLC
PERSONAL and FAMILY INFORMATION
Please describe your child/adolescent’s current living situation. (Members of household, rent or own, etc.)
Who does your child/adolescent consider their strongest and most supportive relationships?
Which relationships, if any, are the most challenging for her / him?
Please describe any family history of mental health, substance use, violence, or abuse issues.
What does your child/adolescent like most about him/herself? What gives him / her strength?
JW Intake Questionnaire (Child / Adolescent)
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Journey Well, LLC
TREATMENT and MEDICAL INFORMATION
Please list the names and dates of any current or previous mental health or substance use treatment,
the type of treatment (inpatient, outpatient, residential, medication management, etc.), and the
reason for the treatment (depression, suicidality, substance abuse, anxiety, grief, etc.).
Name of Provider
Date of Services
Type of Services
Reason for Treatment
Please provide the following information regarding your child/adolescent’s Primary Care Physician.
Name of Physician
Office Location
Telephone Number
Please provide the following information regarding other medical providers involved in her / his care.
Name of Provider
Office Location
Telephone Number
Services Provided
Please list all medications (prescribed or over-the-counter) and supplements he / she currently takes.
Name
Dosage
Reason
Physician (if prescribed)
Please describe medical conditions she / he currently experiences, or any significant medical history.
JW Intake Questionnaire (Child / Adolescent)
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Journey Well, LLC
SUBSTANCE USE and LEGAL INFORMATION
Please provide the following information regarding any legal or illegal substances your child/
adolescent has used or current uses. Please note that names of some substances are already listed,
as well as spaces in which you can write-in other substances. Please mark “N/A” as appropriate.
Name of Substance
Age of
First Use
Date of
Last Use
Type, Frequency
& Amount
Method of Use
(inhale, ingest, snort,
inject, etc.)
Caffeine
Nicotine / Tobacco
Alcohol
Marijuana
Benzodiazepines
Opiates (pain pills)
Opiates (heroin)
Amphetamines
Cocaine / Crack
Please describe difficulties, if any, he/she has experienced or currently experiences related to
substance use. Please list any previous and current treatment on Page 2.
Please describe any past or current involvement in the legal system (such as criminal charges,
incarcerations, probation/parole status, substance-related incidents, domestic violence, etc.)
Thank you for completing this questionnaire. Your responses will be kept confidential and
a counselor will review them with you and your child/adolescent during the intake
appointment.
JW Intake Questionnaire (Child / Adolescent)
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