Mindsoother Therapy Center
2 West Northfield Road, Livingston, NJ 07039
973 220-1885
Adolescent/ Young Adult Intake Form
DATE: _____________________
CLIENT NAME: ___________________________________________________
DATE OF BIRTH:_____________________
AGE: _____________
SCHOOL:_______________________________________
GRADE:_______
MOTHER’S NAME:____________________OCCUPATION:________________
FATHER’S NAME:_____________________OCCUPATION:________________
ADDRESS: _______________________________________________________
CITY/STATE/ZIP:__________________________________________________
________________________________________________________________
TELEPHONES:
Home: ___________________________Child Cell: ______________________
Mother’s Cell: __________________________________
Father’s Cell:____________________________________
EMAIL ADDRESS:________________________________________________
EMERGENCY CONTACT (Name and phone number):
________________________________________________________________
RELATIONSHIP TO CLIENT:________________________________________
WHO REFERRED YOU HERE?:
________________________________________________________________
PRESENTING PROBLEM (be as specific as you can: when did it start, how does
it affect you.):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Estimate the severity of above problem: Mild ____ Moderate ____ Severe ___
CURRENT: Marital status (of parents):___________
SIBLINGS (Names and Ages):
1.
______________________________________________________________
2.
______________________________________________________________
3.
______________________________________________________________
MEDICAL DOCTOR (S) (name/phone):
________________________________________________________________
________________________________________________________________
________________________________________________________________
SPECIFY MEDICATION client is presently taking and for what, including dosage.
PRINT clearly:
________________________________________________________________
________________________________________________________________
FAMILY MEDICAL HISTORY (Describe any illness that runs in the family: e.g.,
cancer, epilepsy, diabetes etc):
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
PAST/PRESENT PSYCHOTHERAPY (with whom and approximately when and
for how long):
1.
________________________________________________________________
________________________________________________________________
2.
________________________________________________________________
________________________________________________________________
3.
________________________________________________________________
________________________________________________________________
What are your goals for your child (adolescent client) for therapy:
1.
________________________________________________________________
________________________________________________________________
2.
________________________________________________________________
________________________________________________________________
3.
________________________________________________________________
________________________________________________________________
Name of Client (print)______________________________________ Date __________________
Client's Signature ________________________________________________________________
Name of Parent (print)______________________________________ Date __________________
Parent’s Signature ________________________________________________________________
Mindsoother Therapy Center
2 West Northfield Road, Livingston, NJ 07039
973 220-1885
Consent For Treatment Of Minor(s) and Adult Child Living in House
I _________________________ give my consent to psychotherapist at Mindsoother, LLC who will
be conduct psychotherapy with (name of client):__________________________________________
My relationship to the client (parent, uncle, etc.): __________________________________________
I was also notified that all material discussed during the psychotherapy sessions is confidential and
can be released only with the permission of the holder of the privilege. I have been informed of the
limitation to confidentiality in the Office Policies form, which I have read and signed.
In the case of a minor, special sensitivity may be required in releasing information about certain
topics. I will accept Mindsoother psychotherapist’s judgment in regard to releasing or sharing
information obtained during the course of psychotherapy. I understand that the therapists at
Mindsoother follow all New Jersey state and Federal Guidelines regarding ethics and confidentiality
in therapy.
The psychotherapists at Mindsoother may contact the responsible party and/or guardian and disclose
information regarding non-attendance, non-payment and/or non-participation in therapy sessions.
________________________________ ______________________________________ __________
Client Name (print)
Signature
Date
________________________________ ______________________________________ __________
Parent Name (print)
Signature
Date
Mindsoother Therapy Center
2 West Northfield Road, Livingston, NJ 07039
973 220-1885
Informed Consent for Treatment
By signing this consent, I authorize psychotherapy services between Mindsoother,
LLC and me or my minor child. I agree that the relationship with client and therapist
is confidential and that this information remains confidential, except when safety is
compromised and with exceptions under New Jersey State Law.
I understand that there is a strict 24-hour cancellation policy for appointments, and that
all appointments missed or not cancelled within 24 hours will be charged the full fee. I
further acknowledge that missed session fees may not be reimbursable by insurance.
__________________(please initial here).
I also agree that this relationship is solely for the purposes of psychotherapy and that
the psychotherapists at Mindsoother, LLC will not engage in assessment or testimony
on my behalf or in any custody assessment or agreement.
I have read the above informed consent, understand, and agree to it.
Name of Client (print)______________________________________ Date _________________
Client's Signature ________________________________________________________________
Name of Parent (print)______________________________________ Date _________________
Parent’s Signature ________________________________________________________________