Child/Adolescent Client Intake Form
Child/Adolescent Client Intake Form
Client's Name: *

First Name Last Name
Nicknames:
Date of Birth: *

Month Day Year
Age: *
Social Security #: *
Please agree to the Terms and Conditionsa of Mosaic Psychological Services below: *

I agree
Home Street Address: *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Person Completing the Form: *

First Name Last Name
Relationship: *
Home/Evening Phone Number: *

Area Code Phone Number
Cell Phone Number: *

Area Code Phone Number
Email
example@example.com
Person Completing form Current Employer:
Employer: *
Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone Number:

Area Code Phone Number
Other means of communication:
Calls will be discrete, but please indicate any restrictions:
May we text your cell phone for appointment reminders? *

Yes No
Emergency Contact Information

If an emergency arises and we cannot reach you directly, or we need to reach someone close to you, whom should we call?
1. Name: *

First Name Last Name
Phone Number *

Area Code Phone Number
Relationship: *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
2. Name:

First Name Last Name
Phone Number:

Area Code Phone Number
Relationship:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PRESENTING PROBLEMS AND CONCERNS
Describe the problem that brought you here today: *

0/1000
Please check all of your child's behaviors and symptoms that you consider problematic: *

Distractibility Change in appetite Visual Hallucinations Manipulative behavior Withdrawal from people Defiance No/few friends Impulsivity Anxiety/worry Aggression/fights Anger/rage attacks Eating problems Bullying others Panic attacks Homicidal thoughts Sleep problems Poor memory/confusion Fear away from home Frequent arguments Nightmares Sadness/depression Social discomfort Irritability/anger Toileting problems/bed wetting Hopelessness Phobias Peer/sibling conflict Firesetting Thoughts of death Obsessive thoughts Stealing Work/School problems Self-harm behaviors Compulsory behavior Destroys property Legal problems Crying spells Racing thoughts Running away Sexual Behavior Pornography use Loneliness Wide mood swings Swearing Video game addiction Low self worth Suspicion/paranoia Curfew/violations Alcohol/drug use Fatigue Hearing voices Lying Lack of motivation Recurring, disturbing memories Hurting or killing animals Poor personal hygene Hoarding or stealing food Other (Please specify below) None
0/500
Are your child's problems affecting any of the following? *

Handling everyday tasks Self esteem Relationships Hygiene Health Recreational activities Work/School Housing Legal matters Finances Family functioning Other (Please specify) None
Has your child ever had thoughts, made statements, or attempted to hurt him/herself? *

Yes No
If yes, please specify

0/1000
Has your child ever had thoughts, made statements, or attempted to hurt someone else? *

Yes No
If yes, please specify

0/1000
Has your child recently been physically hurt or threatened by someone else? *

Yes No
If yes, please specify
FAMILY AND DEVELOPMENTAL HISTORY
Relationship and name of individuals who reside in the home with the Child: *

0/2000
Has your child experienced any of the following in their family life? *

Emotional abuse Neglect Lived in a foster home Sexual Abuse Violence in the home Multiple family moves Physical abuse Crime victim Homelessness Parent substance abuse Parent illness (mental/physical) Loss of a loved one Teen pregnancy Divorce Financial problems None
Were there any medical problems during the pregnancy or birth of your child? *

Yes No
If yes, please specify

0/1000
Did the biological mother use any tobacco, medication, street drugs, or alcohol while pregnant with this child? *

Yes No
If yes, please specify

0/1000
Did your child have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)? *

Yes No
If yes, please specify
Does your child throw intense temper tantrums that appear to be similar to that of a much younger child? *

Yes No
What behavior does your child exhibit when throwing a tantrum?

Spitting Cursing Slamming doors Stomping Removing clothing Breaking objects Destroying property Attempting to run away Making self-harming gestures Urinating or defecating in inappropriate places Screaming and crying N/A
Does your child or teenager have a TV in his or her room? *

Yes No
Are they allowed to have a tablet and/or phone in their room at night? *

Yes No
Does your child watch horror movies or R-rated films? *

Yes No
Does your child or teen have unsupervised access to a TV/tablet/computer/smart phone? *

Yes No
Has your child viewed pornography online (either intentionally or accidentally)? *

Yes No
Please list Apps your child has access or accounts to:

Facebook Twitter YouTube Snapchat WeChat Kik Instagram WhatsApp Pinterest Others (Please list) None
How many hours of screen time (video games, Netflix, TV, tablet, smart phone, etc.) a day does your child have? *
Does your child have nightmares? *

Yes No
If yes, please specify

0/1000
How many hours of sleep does your child get each night? *
What time is bedtime? *
What time do they fall asleep? *
What time do they wake up in the morning? *
How often do they wake up during the night? *
MENTAL HEALTH TREATMENT HISTORY
Please list any previously diagnosed mental illness/conditions: *

Depression/Mood Autism Anxiety Eating Disorder OCD Learning Disability ADHD/ADD Bipolar Sleep Disorder PTSD Schizophrenia Other, please list below N/A
0/500
Does the child have a family history of drug or alcohol addiction or mental illness? *

Yes (Indicate below) No Unknown
0/1000
Has your child ever attempted suicide? *

Yes No
How many times?
At what ages?
Were you hospitalized?

Yes No
Name of Hospital:
Has your child ever threatened suicide? *

Yes No
How many times?
At what ages?
Has your child received any of the following: *

Outpatient Counseling Medication (Mental health)Psychiatric Hospitalization Drug/Alcohol Treatment Self-help/Support groups In-home behavioral therapy N/A
Is your child currently taking mental health medication? *

Yes (Please specify below) No

Prescribing Physician:
Physician Phone Number

Area Code Phone Number

Treatment history (counseling, evaluation, inpatient, etc.): *

Age during treatment:

Name of clinician or facility:

Reason for treatment:

School Information
School Name: *
Current Grade: *
This year's school grades: *

Excellent Good Fair Poor
Past school grades: *

Excellent Good Fair Poor
This year's school behavior: *

Excellent Good Fair Poor
Past school behavior: *

Excellent Good Fair Poor
Has your child had any of the follow difficulties at school? *

Suspension Incomplete homework Learning problems Referrals or detention Poor grades Teased or picked on Speech problems Attendance problems Gang influence N/A
Does your child have an after-school provider? *

Yes (Please specify below the Name of the Provider) No
0/1000
Has your child ever repeated or skipped a grade? *

Yes (Please specify below which grade(s)) No
0/1000
Has your child ever received Special Education/IEP Services? *

Yes No
If yes, please describe services received and reason for services:

0/1000
SUBSTANCE USE HISTORY (for ages 12 and older or if applicable)
Does your child have a history of using or abusing drugs or alcohol? *

Yes No
Substance Type Current Use (last 6 months) *

Tobacco Caffeine (energy drinks, etc.) Alcohol Marijuana Cocaine/Crack Ecstacy Heroine Inhalants Methamphetamines Pain killers PCP/LSD Steroids Tranquilizers Spice None Other: (please specify below)
0/1000
Frequency and Amount:
Has your child had withdrawal symptoms when trying to stop using any substances? *

Yes (Please specify below) No
0/1000
Has your child ever had problems with school, relationships, health, the law, etc. due to his/her substance use? *

Yes (Please specify below) No
0/1000
MEDICAL INFORMATION
Date of Last physical exam:

Month Day Year
Has your child experienced any of the following medical conditions during his/her lifetime: *

Allergies Asthma Headaches Stomach aches Chronic pain Surgery Serious accident Head injury Dizziness/fainting Meningitis Seizures Vision problems High fevers Diabetes Hearing problems Ear infections Miscarriage Abortion Sleep disorder Sexually transmitted disease Other (Please specify below) N/A
0/1000
Please list any CURRENT health concerns: *

0/1000
Medications for general health concerns (not mental health medications): *

0/2000
Current over-the-counter medications (including vitamins, herbal remedies, melatonin, allergy medication, etc.): *

0/1000
Allergies and/or adverse reactions to medications: *

None Yes (Please specify below)
0/1000
Has your child ever had to undergo a CT scan of the head or neck or an EEG? *

Yes (Please specify below why and what year) No
0/1000
Does your child experience periods of time where they "blank out"? *

Yes No
Does your child ever appear "zoned out"? *

Yes No
Has your child ever had fainting spells or problems with balance? *

Yes No
INTERPERSONAL/SOCIAL/CULTURAL INFORMATION
Please describe your child's strengths, skills, and talents? *

0/2000
Describe any special areas of interest or hobbies (art, books, physical fitness, etc.): *

0/2000
LEGAL INFORMATION
If the parents are separated or divorced, what is the current child custody/visitation arrangement? *

0/2000
Is the child currently the subject of a custody case? *

Yes No
Has DFCS ever been involved with your family? *

Yes No
Has your child ever been a ward of the court with DFCS/CPS guardianship? *

Yes No
Does your child have any legal offenses on record or pending in the courts? *

Yes (Please specify below) No
0/2000
I understand that a typed version of my name maybe accepted as my original signature pursuant to the Georgia Uniform ElectronicTransactions Act (O.C.G.A. 10-12-7). To accept the above statement, type"I Understand" in the box below. *
Signature (Please Type Full Name) *
Date *

Month Day Year
Signature *

In order for this submission to be accepted, you must use your mouse to draw your signature in the box above. Clear
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Child/Adolescent Client Intake Form