• Child/Adolescent Client Intake Form

  • Child/Adolescent Client Intake Form

  • Person Completing form Current Employer:

  • 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?

  • PRESENTING PROBLEMS AND CONCERNS

  • 0/1000
  • FAMILY AND DEVELOPMENTAL HISTORY

  • 0/2000
  • MENTAL HEALTH TREATMENT HISTORY

  • School Information

  • SUBSTANCE USE HISTORY (for ages 12 and older or if applicable)

  • MEDICAL INFORMATION

  • 0/1000
  • 0/2000
  • 0/1000
  • INTERPERSONAL/SOCIAL/CULTURAL INFORMATION

  • 0/2000
  • 0/2000
  • LEGAL INFORMATION

  • 0/2000
  • Clear
  • Should be Empty: