Cucamonga Counseling
ADOLESCENT INTAKE FORM (ages 12-17yrs old)
Name:___________________________________
Date:_______________
Birth Date:_______________ Grade:_________ School: _________________
School History
What are your Academic Goals?: Diploma
Trade School
College
Explain: _________________________________________________________
How are you doing in school (i.e. grades, with peers, with teachers, with
coaches)?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Are you in Special Education? ________________________________________
Do you participate in any school sports? ________________________________
________________________________________________________________
Are you in any clubs or other school activities? ___________________________
________________________________________________________________
What do you like best about school? ___________________________________
________________________________________________________________
What do you like least about school? __________________________________
________________________________________________________________
What is your favorite class/subject? ____________________________________
Have you ever been suspended?
Have you ever been expelled?
No
No
Yes
Yes
Do you have a history of fighting in school?
No
Yes
Is there a teacher, counselor, coach, or other adult at school that you can talk to?
No
Yes
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Mental Health History:
Check any symptoms you may have exhibited in the past six months:
___ Sadness/Crying Spells
___ Nervousness/Jittery
___ Socially Isolated
___ Irritable/Temper Outbursts
___ Weight Loss or Gain
___ Persistent Thoughts
___ Insomnia
___ Mood Swings
___ Excessive Sleep
___ Excessive Worrying
___ Loss of interest
___ Fidgety
___ Difficulty Having Fun
___ Nightmares
___ Excessive Anger/Hostility
___ Feeling like you are out of control
___ Suicidal Thoughts/Statements
___ Grieving
___ Difficulty with Authority Figures
___ Easily Distracted
___ Often in Trouble
___ Conflicts with Peers
___ Argumentative
___ Risk taking behavior
___ Alcohol and other drug use
___ Self-injury
___ Change in friends
___ Change in grades
___ Other (please describe):
______________________________________________
Have you ever been hospitalized? If so,why?
________________________________________________________________
________________________________________________________________
________________________________________________________________
List and describe any current or past physical problems (e.g. weight gain,
headaches, stomach aches, etc.):
________________________________________________________________
________________________________________________________________
________________________________________________________________
List and describe any history of emotional disorder(s) in your biological family
(e.g.; addiction, depression, schizophrenia etc.):
________________________________________________________________
________________________________________________________________
________________________________________________________________
2
Have any family members been in counseling or treatment for mental illness or
substance abuse? _________________________________________________
________________________________________________________________
________________________________________________________________
Have you ever received any psychological or counseling services?
Have you ever attempted suicide?
No
Any history of depression or withdrawal?
Any history of sleeping or eating problems?
Physical Abuse?
No
Emotional Abuse?
Sexual Abuse?
No
No
Yes
Yes
Have you ever had suicidal thoughts or gestures?
Any auditory or visual hallucinations?
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Drug/Alcohol Usage and History: _____________________________________
________________________________________________________________
________________________________________________________________
Family History:
Please describe your living arrangements (with whom, time split, etc.) and list
other children in the home(s):
________________________________________________________________
________________________________________________________________
________________________________________________________________
List and describe any significant life events (e.g. divorce, death in family, breakup etc.):
________________________________________________________________
________________________________________________________________
________________________________________________________________
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What adult do you spend most of your time with? (Looking for a positive adult
role model) Name: _________________________________________________
Relationship:______________________________________________________
Which extended family members provide support and how?
Name: ______________________________ Relationship: _________________
History of running away:
No
Yes: (How often, most recent occurrence)
Any previous out of home placements?: No
Locations)
Yes: (Frequency, Duration,
What are your strengths and hobbies? _________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Additional Notes: __________________________________________________
________________________________________________________________
________________________________________________________________
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List your three primary treatment goals:
1._______________________________________________________________
2._______________________________________________________________
3._______________________________________________________________
Diagnosis: (Therapist Completes)
Axis 1 ________________________________________________
Axis II ________________________________________________
Axis III ________________________________________________
Axs IV ________________________________________________
Axis V ________________________________________________
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