Helping Us Understand Your Child: Intake Form

Please remove Form Template Insights before publishing this form

Overall Purpose of a Child and Adolescent Intake Form

The primary purpose of this form is to gather foundational information about a child or adolescent before an initial assessment or therapy session. This allows the professional (therapist, psychologist, psychiatrist, counselor) to:

1. Gain a holistic understanding: Beyond the presenting problem, it provides context about the child's development, health, family, school, and social life.
2. Identify patterns and contributing factors: Information across sections can reveal connections between different areas of the child's life and their current challenges.
3. Prioritize areas for assessment and intervention: The responses help guide the initial interview, allowing the professional to focus on the most relevant or pressing concerns.
4. Establish a baseline: The information serves as a starting point to track progress and evaluate the effectiveness of interventions over time.
5. Inform diagnosis and treatment planning: Detailed history is crucial for accurate diagnosis and for developing a tailored, effective treatment plan.
6. Screen for safety concerns: Questions about self-harm, harm to others, or significant family conflicts can flag immediate safety risks.
7. Identify strengths and resources: Beyond problems, understanding what helps the child thrive can be integrated into a strength-based approach to treatment.

Detailed Insights by Section:

Medical History:

• Purpose: To understand the child's physical health status, which can significantly impact mental health, behavior, and development. Many physical conditions, medications, or sensory impairments can mimic or exacerbate mental health symptoms.
• Current Medications (Name, Dosage, Reason for taking):
• • Insights: Reveals current physiological states, potential side effects of medications (which might mimic psychological symptoms), and existing health concerns being managed. Knowing the reason for taking helps understand underlying conditions.
• Past Medications (if relevant to current concerns):
• • Insights: Provides history of previous treatments, their effectiveness (or lack thereof), and how conditions may have evolved. Important for understanding what has or hasn't worked.
• Allergies (medications, food, environmental):
• • Insights: Crucial for patient safety to prevent adverse reactions. Food allergies can impact diet, social life, and even behavior. Environmental allergies can affect sleep or school attendance.
• Chronic Medical Conditions/Diagnoses (e.g., asthma, diabetes, epilepsy, migraines):
• • Insights: Identifies long-term health issues that might influence a child's energy, mood, ability to attend school, or participation in activities. Chronic illness can also be a significant source of stress, anxiety, or depression.
• Past Hospitalizations/Surgeries (Reason, Date):
• • Insights: Indicates significant past health events, potential trauma, or periods of severe illness. Date helps contextualize developmental stages.
• Serious Injuries/Accidents (Head injuries, concussions, etc.):
• • Insights: Especially important for neurological and cognitive functioning. Head injuries can lead to changes in mood, behavior, concentration, and executive function.
• Vision problems? (Corrected? When was last eye exam?)
• • Insights: Uncorrected vision problems can lead to academic difficulties, headaches, frustration, and misinterpretation of behaviors (e.g., inattention when it's actually difficulty seeing the board).
• Hearing problems? (Corrected? When was last hearing exam?)
• • Insights: Uncorrected hearing issues can impact language development, social interaction, academic performance, and lead to feelings of isolation or misbehavior due to mishearing instructions.
• Sleep patterns: (Hours of sleep, difficulty falling/staying asleep, nightmares, night terrors, bedwetting)
• • Insights: Sleep is fundamental to physical and mental health. Disturbances can be symptoms of underlying mental health conditions (e.g., anxiety, depression, ADHD) or contributing factors to behavioral issues, irritability, and poor concentration. Bedwetting can be linked to stress, anxiety, or developmental factors.
• Eating habits/patterns: (Picky eating, restrictive eating, excessive eating, weight concerns)
• • Insights: Eating habits can reflect psychological issues (e.g., anxiety leading to picky eating, control issues in restrictive eating, emotional regulation in excessive eating). Weight concerns are directly tied to physical health and body image, which can impact self-esteem and social functioning.
• Does your child have a primary care physician? (Name, Contact Info - optional)
• • Insights: Important for coordination of care, obtaining collateral information, and ensuring holistic health management.
• Has your child seen any other specialists (e.g., neurologist, pediatrician, geneticist)? (Name, Type of Specialist, Reason, Date)
• • Insights: Reveals previous concerns about specific systems or conditions, potential diagnoses, and other professionals involved in the child's care, allowing for communication and collaboration.

Educational History

• Purpose: School is a primary environment for children and adolescents. Understanding their performance, behavior, and social interactions in this setting provides crucial insight into their overall functioning and potential challenges.
• Current School (Name, Type of School - public, private, home-schooled):
• • Insights: Provides context for the child's learning environment and peer group. Home-schooling, for instance, might impact social opportunities.
• Grade Level:
• • Insights: Basic demographic information to contextualize academic and social expectations.
• Current Academic Performance (Please describe strengths and weaknesses in different subjects):
• • Insights: Direct measure of cognitive functioning, learning styles, and potential learning disabilities. Weaknesses can highlight areas of struggle, while strengths can be leveraged for interventions.
• Are there any current academic concerns? (e.g., struggling with specific subjects, difficulty with homework, poor grades, lack of motivation)
• • Insights: Pinpoints specific areas of academic distress that might be related to learning disorders, ADHD, anxiety, depression, or external stressors.
• Has your child ever received any special educational support or accommodations (e.g., IEP, 504 plan, extra help, tutoring)? If yes, please describe.
• • Insights: Indicates a history of identified learning or behavioral challenges that required formal support. Provides documentation of previous interventions and diagnoses.
• Has your child ever been suspended or expelled from school? If yes, please describe the circumstances.
• • Insights: Highlights significant behavioral problems, disciplinary issues, or challenges with authority figures and rule-following. Understanding the circumstances is key to discerning root causes.
• How does your child typically interact with teachers and peers at school?
• • Insights: Reveals social skills, relationship patterns with adults and peers, and potential issues with authority or social anxiety.
• Does your child enjoy school?
• • Insights: A general indicator of well-being and engagement. Dislike for school can stem from academic struggles, bullying, social anxiety, or other mental health issues.

Family History and Dynamics

• Purpose: The family environment is the most influential system for a child. Understanding family structure, relationships, and history of mental health provides crucial context for the child's development and current difficulties.
• Family Composition:
• • Who lives in the home with the child/adolescent? (List names, relationship to child, and ages)
  • • Insights: Basic demographic information about the immediate living situation and household members.
  • Are there other significant adults in the child's life (e.g., grandparents, aunts/uncles)?
  • • Insights: Identifies additional support systems or potential stressors outside the immediate household.
  • Have there been any significant changes in family structure (e.g., separation, divorce, remarriage, new siblings, death of a family member, adoption)? If yes, please describe the impact on the child.
  • • Insights: Major life transitions are significant stressors for children. Understanding the nature and impact of these changes is vital for contextualizing emotional or behavioral shifts.
• Family Relationships:
• • How would you describe the general atmosphere in your home?
  • • Insights: Provides a qualitative sense of the emotional climate of the home (e.g., calm, chaotic, tense, loving).
  • How do family members typically communicate with each other?
  • • Insights: Reveals communication patterns – open, indirect, conflictual, avoidant. This impacts how issues are addressed and resolved.
  • What are the family rules and routines? How consistent are they?
  • • Insights: Highlights structure, predictability, and discipline in the home. Inconsistency can contribute to behavioral problems.
  • Are there any significant family conflicts or stressors? (e.g., financial difficulties, parental health issues, marital problems, substance use, domestic violence)
  • • Insights: Identifies major external and internal stressors impacting the family unit, which can directly affect the child's well-being and presenting problems. Substance use and domestic violence are critical safety concerns.
  • How does your child typically interact with siblings?
  • • Insights: Reveals peer-like relationships within the home, including potential rivalry, support, or conflict.
  • How would you describe your relationship with your child?
  • • Insights: Assesses the parent-child bond, which is a key factor in a child's resilience and capacity for healthy development.
• Family Mental Health/Substance Use History:
• • Purpose: Genetic predispositions and learned behaviors play a significant role in mental health. Understanding family history helps identify risk factors and potential patterns.
  • Insights: Provides crucial information for differential diagnosis. Many mental health conditions have a genetic component or are influenced by the family's modeling of coping mechanisms. For instance, a strong family history of anxiety might suggest a genetic predisposition or learned anxious behaviors. Substance use in the family can indicate both genetic risk and environmental exposure to unhealthy coping. Suicide attempts are a critical warning sign for increased risk in the child.

Strengths and Interests

• Purpose: This section is vital for a strength-based approach to treatment. Focusing solely on problems can be demoralizing. Identifying strengths and interests helps build rapport, boosts self-esteem, and provides resources for coping and engagement in therapy.
• What are your child's strengths, talents, and positive qualities? (e.g., kind, humorous, artistic, athletic, intelligent, resilient, good problem-solver)
• • Insights: Helps the professional see the whole child, not just their challenges. These strengths can be leveraged in therapy (e.g., using art for expression, sports for social connection or stress relief).
• What activities does your child enjoy? (e.g., sports, music, art, reading, video games, outdoor activities)
• • Insights: Provides avenues for positive engagement, building self-esteem, and social connection. Can also be used as motivators or part of a behavioral plan.
• What helps your child feel happy, calm, or successful?
• • Insights: Identifies existing coping strategies and calming techniques that the child already uses, which can be reinforced or built upon.

Previous Professional Help

• Purpose: To understand the history of previous interventions, their perceived effectiveness, and any prior diagnoses. This prevents redundant assessments and informs future treatment directions.
• Has your child ever received psychological, psychiatric, or counseling services before? (Name of professional/agency, Dates of service, Reason for seeking help, Outcome of treatment)
• • Insights: Reveals attempts at intervention, what was tried, for how long, and if it helped. Helps understand parental expectations and previous experiences with mental health services.
• Has your child ever been evaluated for developmental, learning, or mental health concerns? (e.g., psychological testing, psychoeducational assessment) If yes, please provide details and any diagnoses received.
• • Insights: Provides official diagnostic history, a deeper understanding of cognitive or developmental profiles, and a basis for current assessment or treatment. Avoids re-doing expensive assessments if recent ones exist.

Additional Information

• Purpose: This serves as a catch-all for any information the parents feel is important but wasn't explicitly asked.
• Is there anything else you would like us to know about your child/adolescent or your family that you feel is important for us to understand?
• • Insights: Empowers parents to share unique or sensitive details they deem relevant. Often, critical pieces of information emerge here that might not fit into other categories. It signals to the parent that their perspective is valued.

Please remove this mandatory questions recommendation before publishing.

The "mandatory" nature of questions on an intake form often depends on the specific context:

• Legal/Ethical Obligations: Some questions are mandatory due to legal reporting requirements (e.g., suspected child abuse/neglect) or ethical guidelines for ensuring patient safety.
• Clinical Necessity: Many questions are mandatory because the information is absolutely essential for safe and effective assessment, diagnosis, and treatment planning. Without this data, the professional cannot adequately provide care.
• Clinic Policy: A clinic might have its own internal policies deeming certain information essential for all new clients.

Based on your provided Child and Adolescent Intake Form, here are the questions that are likely to be considered mandatory (or highly essential) and why:

Medical History from IV. Development History:

1. Current Medications (Name, Dosage, Reason for taking):
2. • Why: Critical for patient safety. Medications can have side effects that mimic or exacerbate psychological symptoms, or they may interact with future psychiatric medications. Knowing the reason helps understand underlying health conditions.
2. Allergies (medications, food, environmental):
3. • Why: Absolute safety priority. Failure to know about allergies can lead to life-threatening reactions. This is non-negotiable medical information.
3. Serious Injuries/Accidents (Head injuries, concussions, etc.):
4. • Why: Head injuries, especially concussions, can have profound and lasting impacts on cognitive function, mood, and behavior. This information is crucial for understanding potential neurological contributions to presenting symptoms.
4. Has your child ever expressed thoughts of harming themselves or others? (from Section VI.B Emotional Regulation)
5. • Why: Immediate safety concern. This is a direct question about self-harm or homicidal ideation and is often the most critical question on an intake form. Professionals have a duty of care and legal reporting obligations if there's an imminent risk.

VI. Social and Emotional History (Specific Safety Concerns)

1. Does your child engage in self-injurious behaviors (e.g., cutting, scratching, head-banging)?
2. • Why: Immediate safety concern. Non-suicidal self-injury indicates significant distress and requires immediate clinical attention and safety planning.
2. Has your child ever expressed thoughts of harming themselves or others?
3. • Why: Immediate safety concern. As mentioned above, this is paramount for safety assessment and intervention.

VII. Family History and Dynamics (Safety & Legal Obligations)

1. Have there been any significant changes in family structure (e.g., separation, divorce, remarriage, new siblings, death of a family member, adoption)? If yes, please describe the impact on the child.
2. • Why: Major family changes are significant life stressors and can profoundly impact a child's mental and emotional well-being. Understanding these dynamics is essential for contextualizing current problems. This often uncovers trauma or significant adjustment issues.
2. Are there any significant family conflicts or stressors? (e.g., financial difficulties, parental health issues, marital problems, substance use, domestic violence)
3. • Why: Critical for identifying potential safety risks and environmental stressors. Domestic violence and parental substance use are red flags for child protection concerns and potential abuse/neglect, which often triggers mandatory reporting obligations for professionals.

IX. Previous Professional Help

1. Has your child ever received psychological, psychiatric, or counseling services before?
2. • Why: Understanding previous therapeutic interventions provides context. It helps determine what has been tried, what worked/didn't work, and prevents redundant assessments or treatments.
2. Has your child ever been evaluated for developmental, learning, or mental health concerns? If yes, please provide details and any diagnoses received.
3. • Why: Prior evaluations and diagnoses are crucial for treatment planning. It helps validate existing diagnoses, avoid unnecessary re-testing, and understand the child's historical challenges and strengths from a professional perspective.