Child Intake Form
Child Psychosocial History
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Email *
Today's date *
MM
/
DD
/
YYYY
Client name:
Date of birth:
Completed by:
Relationship to client:
Presenting problem (as described by caregiver):
History of Presenting Problem:
When was it first noticed?
How often does it occur?
How severe is the problem?
What interventions have been attempted to resolve the problem, by parent or other caregiver?
Has the child been in therapy before?
If yes, please describe who, when and reason for termination of treatment.
Is the child involved with other service providers at school or outside agencies?
If yes, please list:
What are the child's strengths (as described by caregiver)?
What are the family's strengths?
What are some current stressors for child or family?
Please rate your child on each behavior
(0=never, 1=occasionally, 2=frequently, 3=almost always)
Excessive crying/colicky
Never
Almost Always
Clear selection
Cannot be consoled by caregiver
Never
Almost Always
Clear selection
Feeding problems (refuses to eat, very selective, eats non-food objects)
Never
Almost Always
Clear selection
Destructive or aggressive behavior (hitting, kicking, biting, breaking things, throwing things)
Never
Almost Always
Clear selection
Frequent tantrums (more than once a day, lasting over 30 minutes)
Never
Almost Always
Clear selection
Self-injurious behavior (head banging, cutting or scratching self)
Never
Almost Always
Clear selection
Repetitive behaviors (tics, repetitive movements, habits or compulsions)
Never
Almost Always
Clear selection
Makes suicidal/homicidal statements or gestures
Never
Almost Always
Clear selection
Impulsive behavior (runs into street, climbs excessively)
Never
Almost Always
Clear selection
Few or no words/language delay
Never
Almost Always
Clear selection
Night terrors or frequent night waking
Never
Almost Always
Clear selection
Preoccupation with routines
Never
Almost Always
Clear selection
Difficulties sitting still and attending quiet tasks
Never
Almost Always
Clear selection
Toilet training difficulties or delays
Never
Almost Always
Clear selection
Lack of coordination
Never
Almost Always
Clear selection
Loss of previously gained skills
Never
Almost Always
Clear selection
Fidgets, seems restless, or as if driven by a motor
Never
Almost Always
Clear selection
Sensitivity to noises, sounds, textures or smells
Never
Almost Always
Clear selection
Does not like to dress/act/play in ways typically associated with their own gender
Never
Almost Always
Clear selection
Reports phobias or fears
Never
Almost Always
Clear selection
Dawdles in getting dressed
Never
Almost Always
Clear selection
Dawdles or lingers at mealtime
Never
Almost Always
Clear selection
Has poor table manners
Never
Almost Always
Clear selection
Refuses to eat food presented
Never
Almost Always
Clear selection
Refuses to do chores when asked
Never
Almost Always
Clear selection
Slow in getting ready for bed
Never
Almost Always
Clear selection
Refuses to go to bed on time
Never
Almost Always
Clear selection
Does not obey house rules on own
Never
Almost Always
Clear selection
Refuses to obey until threatened with punishment
Never
Almost Always
Clear selection
Acts defiant when told to do something
Never
Almost Always
Clear selection
Argues with parents about rules
Never
Almost Always
Clear selection
Gets angry when doesn't get own way
Never
Almost Always
Clear selection
Has temper tantrums
Never
Almost Always
Clear selection
Sasses adults
Never
Almost Always
Clear selection
Whines
Never
Almost Always
Clear selection
Cries easily
Never
Almost Always
Clear selection
Yells or screams
Never
Almost Always
Clear selection
Hits parents
Never
Almost Always
Clear selection
Destroys toys and other objects
Never
Almost Always
Clear selection
Is careless with toys and other objects
Never
Almost Always
Clear selection
Steals
Never
Almost Always
Clear selection
Lies
Never
Almost Always
Clear selection
Teases or provokes other children
Never
Almost Always
Clear selection
Verbally fights with friends own age
Never
Almost Always
Clear selection
Verbally fights with sisters and brothers
Never
Almost Always
Clear selection
Physically fights with friends own age
Never
Almost Always
Clear selection
Physically fights with sisters and brothers
Never
Almost Always
Clear selection
Constantly seeks attention
Never
Almost Always
Clear selection
Interrupts
Never
Almost Always
Clear selection
Is easily distracted
Never
Almost Always
Clear selection
Has short attention span
Never
Almost Always
Clear selection
Fails to finish tasks or projects
Never
Almost Always
Clear selection
Has difficulty entertaining self alone
Never
Almost Always
Clear selection
Has difficulty concentrating on one thing
Never
Almost Always
Clear selection
Is overractive or restless
Never
Almost Always
Clear selection
Wets the bed
Never
Almost Always
Clear selection
Please list everyone residing with the child, including hired help:
Family History
Is there a family history of mental illness?
If yes, please describe:
Are any family members affected by substance abuse issues?
If yes, please describe:
Has the child experienced any losses of, or separations from, significant family members?
Are there any past or current stressors on the child and/or family? (e.g. divorce, conflict, illness, loss of income, move, major family change, etc.)
Has the child ever experienced or witnessed any trauma? (e.g. events that threaten the child's sense of safety: physical, verbal, or sexual abuse, severe neglect, etc.)
If yes, please describe:
Has your child ever self-harmed (cutting) or attempted suicide? 
Clear selection
If yes, please describe? Was your child been hospitalized? 
Home Life
Please describe a typical school/weekday for your child:
Please describe a typical weekend day for your child:
Does your family have rules for screen time? If yes, please describe:
If no, please indicate how much time your child spends using a screen on a typical day:
Is screen time a source of conflict for your family? If yes, please describe:
Does your family participate in any organized religion?
How often does your family eat meals together?
Which caregiver/adult does your child spend the most time with?
What information, if any, has your child been given about human sexuality? Please describe:
Medical Information
Any current or past medical issues:
Name and contact info of child's pediatrician:
Is child currently on any medication?
Allergies:
Developmental History
Please give the approximate ages your child reached the following milestones:
Rolled over
Smiled
Sat up
Crawled
Walked
Talked (single words)
Made sentences
Toilet trained
School History
Does child have friends?
Does child have any difficulties engaging with peers? (e.g. bullying, conflicts, etc.)
If child has a sibling, how do they get along?
Treatment Goals
Describe your expected outcomes for therapy:
Additional comments:
Thank you!
A copy of your responses will be emailed to the address you provided.
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