Child Intake - Mental Health Counseling and parent coaching

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					                                            Child Intake Record

A. Identification

Child’s name: _________________________________________ Birthdate:___________ Age:_____

Person(s) completing this form: _____________________________________Today’s date: __________

Child lives with:________________________________________________________________________

Child’s custodian/guardian is:_____________________________________________________________

Mother’s name: ______________________________________ Birthdate:___________

Home phone: __________________ Work phone: ___________________Email:__________________

Address: _____________________________________________________________________________

Currently employed (circle one):      No Yes         Job Title:____________________________________

Father’s name: ______________________________________ Birthdate: _____________

Home phone: __________________ Work phone: ____________________Email:__________________

Address: _____________________________________________________________________________

Currently employed (circled one):     No Yes       Job Title:_____________________________________

Parents are currently (circle one): Married      Divorced         Remarried   Never married   Other

Stepparent’s name and information: _______________________________________________________

Siblings (names and ages) _______________________________________________________________

_____________________________________________________________________________________

B. Development: Please fill in any information you have on the areas listed below.

1. Pregnancy and delivery

Prenatal medical illnesses and health care:

Was the child premature?          Weight and height at birth:

Any birth complications or problems?

2. The first few months of life

Breast-fed?             If so, for how long?
Any allergies?

Sleep patterns or problems:

Personality:

3. Milestones: At what age did this child do each of these?

Sat without support:

Crawled:

Walked without holding on:

Ate with a fork:

Helped when being dressed:

Stayed dry all day:

Stayed dry all night:

4. Speech/language development

Age when child said first word understandable to a stranger:

Age when child said first sentence understandable to a stranger:

Any speech, hearing, or language difficulties?

4. Health

List all past childhood illnesses:

Hospitalizations, surgeries?

Head injuries?

Serious accidents and injuries?

Loss of consciousness, convulsions/seizures?

Other medical conditions?

Current conditions:_____________________________________________________________________

Current medications:____________________________________________________________________

Doctor:______________________________________________ Phone:__________________________
D. Residences

1. Homes

Locations and dates?

With who has child lived?

Reason for moving:

Did child have any problems with the move(s)?



2. Residential placements, institutional placements, or foster care

Dates:

Program name or location:

Reason for placement?

Problems with placement?

E. Schools

Current school:_____________________________________________ Address: ___________________

_____________________________________ Phone:____________________________ Grade:_______

Teacher:___________________________________ School district:______________________________

How many schools has your child attended?

Was your child ever retained?

Does your child have any challenges at school?

Does your child receive special services?

May I call and discuss your child with the current teacher (circle one)?   Yes   No

F. Personal Information

Hobbies, sports, and other special interests:_________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________
Pets:_________________________________________________________________________________

Child’s Strengths:_______________________________________________________________________

_____________________________________________________________________________________

Child’s challenges:______________________________________________________________________

_____________________________________________________________________________________

Assigned chores:_____________________________________________________________________

G. Parenting Information

Describe your basic approach to behavior management:_______________________________________


____________________________________________________________________________________

Describe your child’s response to this approach:______________________________________________

_____________________________________________________________________________________

What type of help or support would you like for parenting?_____________________________________

_____________________________________________________________________________________

G. Counseling Services

Has your child received counseling services in the past?                  If so, when and with who?______

_____________________________________________________________________________________

List the top three goals for your child’s growth and general adjustment:

_____________________________________________________________________________________

_____________________________________________________________________________________

Child Checklist of Characteristics
Mark any items that describe your child. Feel free to add any others at the end under “Any other
characteristics.”
❑ Affectionate
❑ Argues, “talks back,” smart-alecky, defiant
❑ Bullies/intimidates, teases, inflicts pain on others, is bossy to others, picks on, provokes
❑ Cheats
❑ Cruel to animals
❑ Concern for others
❑ Conflicts with parents over persistent rule breaking, money, chores, homework, grades, choices in
music/clothes/hair/friends
❑ Complains
❑ Cries easily, feelings are easily hurt
❑ Dawdles, procrastinates, wastes time
❑ Difficulties with parent’s paramour/new marriage/new family
❑ Dependent, immature
❑ Developmental delays
❑ Disrupts family activities
❑ Disobedient, uncooperative, refuses, noncompliant, doesn’t follow rules
❑ Distractible, inattentive, poor concentration, daydreams, slow to respond
❑ Dropping out of school
❑ Drug or alcohol use
❑ Eating—poor manners, refuses, appetite increase or decrease, odd combinations, overeats
❑ Exercise problems
❑ Extracurricular activities interfere with academics
❑ Failure in school
❑ Fearful
❑ Fighting, hitting, violent, aggressive, hostile, threatens, destructive
❑ Fire setting
❑ Friendly, outgoing, social
❑ Hypochondriac, always complains of feeling sick
❑ Immature, “clowns around,” has only younger playmates
❑ Imaginary playmates, fantasy
❑ Independent
❑ Interrupts, talks out, yells
❑ Lacks organization, unprepared
❑ Lacks respect for authority, insults, dares, provokes, manipulates
❑ Learning disability
❑ Legal difficulties—truancy, loitering, panhandling, drinking, vandalism, stealing, fighting, drug sales
❑ Likes to be alone, withdraws, isolates
❑ Lying
❑ Low frustration tolerance, irritability
❑ Mental retardation
❑ Moody
❑ Mute, refuses to speak
❑ Nail biting
❑ Nervous
❑ Nightmares
❑ Need for high degree of supervision at home over play/chores/schedule
❑ Obedient
❑ Obesity
❑ Overactive, restless, hyperactive, overactive, out-of-seat behaviors, restlessness, fidgety, noisiness
❑ Oppositional, resists, refuses, does not comply, negativism
❑ Prejudiced, bigoted, insulting, name calling, intolerant
❑ Pouts
❑ Recent move, new school, loss of friends
❑ Relationships with brothers/sisters or friends/peers are poor—competition, fights, teasing/provoking,
assaults
❑ Responsible
❑ Rocking or other repetitive movements
❑ Runs away
❑ Sad, unhappy
❑ Self-harming behaviors—biting or hitting self, head banging, scratching self
❑ Speech difficulties
❑ Sexual—sexual preoccupation, public masturbation, inappropriate sexual behaviors
❑ Shy, timid
❑ Stubborn
❑ Suicide talk or attempt
❑ Swearing, blasphemes, bathroom language, foul language
❑ Temper tantrums, rages
❑ Thumb sucking, finger sucking, hair chewing
❑ Tics—involuntary rapid movements, noises, or word productions
❑ Teased, picked on, victimized, bullied
❑ Truant, school avoiding
❑ Underactive, slow-moving or slow-responding, lethargic
❑ Uncoordinated, accident-prone
❑ Wetting or soiling the bed or clothes
❑ Work problems, employment, workaholism/overworking, can’t keep a job
Any other characteristics:
❑
Please look back over the concerns you have checked off and choose the one that you most want your
child to be helped with. Which is it?

				
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posted:8/12/2011
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