Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
Date: __________________________________________________
Child/Adolescent Intake Form
Client Name:___________________________________________________________________________DOB_______________________AGE:____________________
Address: ______________________________________________________________________________________________________________________________________
Street
City
Zip Code
Name of Person completing form: _______________________________________________________________________________________________________
Relationship to child: ___________________________________________________
With whom does the child reside: (circle)
Biological Parents
Adoptive Parents
Foster Parents
DHS Home
Other: ____________________________________________________________________
Parent Information:
Mother’s Name: __________________________________________________________________________________________________ Age: _____________
Address: __________________________________________________________________________________________________ Phone: ___________________________
Father’s Name: ___________________________________________________________________________________________________ Age: ______________
Address: _________________________________________________________________________________________________ Phone: ____________________________
Marital Status of Biological/adoptive parents: (circle)
Married
Married
Divorced
Separated
Widowed
Never
If separated/divorced, who has legal custody:_______________________________________*Please Provide Legal Documentation
Date of separation/divorce: ___________________________ If a parent is deceased, what was the date of death: _________________________
If Parents are remarried:
Date of remarriage: _______________________________
Stepmother’s Name: ________________________________________________________________________________________________________________________
Stepfather’s Name: __________________________________________________________________________________________________________________________
Presenting Problem: Please describe the problem that has brought you here today: _______________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Client Name:
Date:
1
Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
Please check any symptom/problems your child/adolescent has been experiencing:
☐ Having suicidal thoughts
☐ Breaks laws/rules
☐ Has a plan to kill self
☐ Panic Attacks
☐ Low mood
☐ Afraid/unable to leave home/parent
☐ Difficulty falling/staying asleep
☐ Extreme unreasonable fears
☐ Excessive sleeping
☐ Intense fear of social situations
☐ Change in appetite-decreased or increased
☐ Trouble by repetitive thoughts or behaviors
☐ Difficulty concentrating
☐ Intrusive, upsetting memories of past events
☐ Lost interest in previously enjoyed activities
☐ Using alcohol or other illegal substance
☐ Decreased energy
☐ Sexually active (_______Straight_________Gay________Bi)
☐ Tense or more irritable than usual
☐ Gender identification
☐ Excessive worry
☐ Problems within the family
☐ Argumentative
☐ Problems with Friends
☐ Aggressive behavior/communication
☐ Educational/school problems
☐ Destructive or violent thoughts or behavior
☐ Problems at work
☐ Attempts to hurt, harm, or mutilate self
☐ Housing problems
☐ Anger outbursts
☐ Financial/economic problems in the family
☐ Disobedient
☐ Problems with the legal system
☐ Cruel to animals
☐ Careless, high-risk behavior
☐ Fire setting
☐ Highly elevated mood/excessive energy
☐ Runaway
☐ Hyperactivity/Inattention
Other symptoms you’ve observed: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Has your child/adolescent ever attempted to take his/her own life? No
Yes
Has your child/adolescent ever purposely cut or burned her/himself? No Yes
If yes, when? _________________________________
If yes, when? _________________________________
Please describe when the current problems began and how they affect your child/adolescent’s functioning at home, school,
with friends and in other areas of life: _____________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
What are your goals/expectations for treatment:_________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Client Name:
Date:
2
Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
PAST MENTAL HEALTH TREATMENT
Has your child/adolescent ever received outpatient mental health treatment/counseling before:
YES
NO
If Yes, why, when and where: ______________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________
Has your child/adolescent ever been hospitalized for mental health/behavioral reasons?
YES
NO
If yes, please describe why, when, and where: ____________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Please list any mental health diagnoses your child/adolescent has been given:________________________________________________________
_________________________________________________________________________________________________________________________________________________
Medications: Please list all medications your child/adolescent is currently taking:
Medication
Dosage
Purpose
To your knowledge, has your child/adolescent ever used illegal drugs or abused prescription drugs?
YES
NO
If yes, please describe: _______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Does your child/adolescent:
Smoke
Smokeless Tobacco
If you have circled one of the above, is this behavior
Client Name:
current
Drink Alcohol
Drink Beer
NONE
past
Date:
3
Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
HEALTH INFORMATION
How would you describe your child’s overall health? (circle)
Does your child/adolescent have chronic medical problems?
GOOD
Yes
FAIR
POOR
No
If Yes, please describe: _______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Has your child/adolescent ever experienced a head injury, loss of consciousness, or seizure?
Yes
No
If Yes, please describe: ______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Does the child/adolescent have a history of any serious injuries or medical problems?
Yes
No
If Yes, please describe: ______________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Please list any problems experienced by the mother during her pregnancy, labor, or delivery with this child: _____________________
_________________________________________________________________________________________________________________________________________________
Did the mother smoke, drink, or use any illicit or harmful drugs during this pregnancy?
Yes
No
If Yes, please explain: ________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
FAMILY INFORMATION
Is this child/adolescent your biological child?
Yes
If No, what age was he/she adopted or came to live with you?
Is there contact with both biological parents?
Yes
No
________________
No
Please explain: ____________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Is there conflict in the home, such as problems in parents marriage or problems with parenting?
Yes
No
Please explain: ______________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Client Name:
Date:
4
Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
*Are you involved in any litigation, such as custody or visitation changes related to your child?
Yes
No
_________________________________________________________________________________________________________________________________________________
*I will not get involved in a custody/visitation issue with children/adolescents that I am seeing for counseling.
Who lives in this child/adolescent’s home:
Name
Age
Relationship to child
Quality of Relationship
1
2
3
4
5
6
If your child/adolescent spends time at another parents home, please list household members of that home:
Name
Age
Relationship to child
Quality of Relationship
1
2
3
4
5
6
Does this child/adolescent have grandparents that are significant in their lives?
Yes
No
Name
Paternal
Maternal
Name
Paternal
Maternal
Name
Paternal
Maternal
Name
Paternal
Maternal
Client Name:
Date:
If yes:
5
Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
Family Mental Health History
Please check any mental health issues that your child/adolescent’s family member (include parents, siblings, grandparents,
aunts, uncles, cousins) have/had.
_________Depression
__________Anxiety
_____________ADHD
___________BiPolar
_________Schizophrenia
__________Alcohol/Drug Problems _____________Learning Disability ___________Panic Disorder
_________Autism Spectrum
__________Mental Retardation
_____________”Nervous Breakdown” ___________PTSD
_________Suicide or attempted
__________ OCD (Obsessive/Compulsive Disorder)
SOCIAL ISSUES
Does your child/adolescent have quality relationships with other children?
Does your child/adolescent tend to spend more time with
Yes
OLDER
YOUNGER
No
SAME AGE
children?
Do you have concerns about your child’s/adolescent’s friends?
Yes
No
If yes, explain: ________________________________________________________________________________________________________________________________
EDUCATION
Where does your child attend school? _____________________________________________________________________________________________________
If homeschooled, who does the instruction: _______________________________________________________________________________________________
What grade level is he/she in? _______________________ What are his/her typical grades? _____________________________________________
Has your child ever been held back?
YES
NO
What are his/her academic strengths? ______________________________________weaknesses?_______________________________________________
Has there been a change in his/her academic performance?
YES
NO
If YES please explain: ________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Has your child ever received Academic or IQ testing?
YES
NO
If yes, who did the testing and what were the results: ____________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
(A copy of this report for his/her file would be helpful)
Does your child have an I.E.P.?
YES
Is your child in Accelerated or Honors programs?
NO
YES
If yes, describe: _____________________________________________________
NO
Has your child/adolescent had problems with any of the following:
YES
NO
Truancy, explain: ______________________________________________________________________________________
YES
NO
Fighting, explain: ______________________________________________________________________________________
YES
NO
Absenteeism, explain: _________________________________________________________________________________
YES
NO
Detention, explain: ____________________________________________________________________________________
Client Name:
Date:
6
Linda Kastner, L.P.C.
9826 N.E. 23rd. St.  Midwest City, OK73141
Phone: (405) 769-4799  FAX: (405) 260-9465
YES
YES
NO
NO
Suspensions explain: _________________________________________________________________________________
School refusal, explain: _______________________________________________________________________________
INTERESTS AND ACTIVITIES
What are your child’s/adolescent’s favorite activities: ___________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
Does your child/adolescent have any particular talents? ________________________________________________________________________________
What are the things you like most about your child/adolescent: ___________________________________________________________________
_________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________
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______________________________________________________________________________________________
Signature of person completing this form
_________________________________________
Date
Office use only below this line
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Notes:
Initial Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Client Name:
Date:
7