Issuu on Google+

Rachel Falbo Counseling ADOLESCENT/MINOR INTAKE FORM Date of First Appointment: ______________

Age: ________________________

Name:________________________________________________________________________ Last First MI DOB ______________________________________________________________________________ Address ______________________________________________________________________________ City State Zip Code Contact Information: _________________ _______________ _________________________ Home Cell email Race/Ethnicity:

African American _____ Asian _____ Caucasian _____ Latin _____ Native American _____ Other _____

What grade are you currently in? ___________________________________________________ Please list the grades received on your last report card or your current GPA: ______________________________________________________________________________ What types of extracurricular activities are you involved in? _____________________________ ______________________________________________________________________________ Are you currently employed? ____________ Employer: ________________________________ Please list all of your family members: Name

Age

Relationship

Residence

Briefly describe your reason for seeking counseling: ______________________________________________________________________________ ______________________________________________________________________________

1


Rachel Falbo Counseling ADOLESCENT/MINOR INTAKE FORM What goals do you hope to achieve by attending counseling? ______________________________________________________________________________ ______________________________________________________________________________ Pediatrician: ___________________________________ Phone #: ________________________ When were you last examined by a physician? ______________________________________________________________________________ List any major health problems for which you currently receive treatment: ______________________________________________________________________________ ______________________________________________________________________________ Please list any medications you are currently taking: Medication

Dosage

Condition

Treating Provider

Length of use of Medication

Current Height _______________________ Current Weight _______________________ Are you currently involved in an exercise regimen? Yes ______ No _______ If yes, please list the type of exercise and amount per week ______________________________________________________________________________ Current hobbies/personal interests: ______________________________________________________________________________ ______________________________________________________________________________

2


Rachel Falbo Counseling ADOLESCENT/MINOR INTAKE FORM Current religious/spiritual beliefs: ______________________________________________________________________________ ______________________________________________________________________________ Please answer the following as it applies to you: Do you currently have a license to drive? ____________________________________________ Are you currently sexually active? _________________________________________________ Do you currently feel pressure from peers to do things you don’t want to do? ______________________________________________________________________________ ______________________________________________________________________________ Are you now, or have you ever been bullied at school? _________________________________ Are you currently or have you in the past been involved in any gang/criminal activity? ______________________________________________________________________________ Do you currently drink alcohol and if so please state the amount consumed per day/week: ______________________________________________________________________________ Do you currently smoke and if so please state the amount consumed per day/week: ______________________________________________________________________________ Do you currently use any controlled substances and if so please state the amount consumed per day/week: _____________________________________________________________________ How many times per week does your family sit down for meals together? ______________________________________________________________________________ Have you ever previously attended therapy or received counseling services of any kind? Yes _______ No _______ If yes please list the type of therapy you received ______________________________________________________________________________

3


Rachel Falbo Counseling ADOLESCENT/MINOR INTAKE FORM Did you find treatment helpful? ____________________________________________________ Previous therapist: ______________________________________________________________ Reason treatment terminated? _____________________________________________________ Previous psychiatric hospitalizations? _______________________________________________ Treatment and Diagnosis Rendered? ________________________________________________ Have you ever struggled with any of the following symptoms/behaviors? No

Yes

If yes, when?

Anorexia/Bulimia Drugs/Alcohol Fighting Cutting Suicidal thoughts/attempts Homicidal thought Runnings away Truancy Depression Anxiety Gang/criminal activity Tell me briefly if you or anyone in your family has ever been affected by the following: Self Alcoholism/Drugs Obesity Anorexia/Bulimia Mental Illness Terminal Illness Sexual assault Abuse/Domestic Violence Chronic Health Problems Criminal Activity CPS Involvement Child Abuse Depression/Anxiety

4

Sibling(s)

Parent(s)

Aunt/Uncle Grandparent(s) Other


Adolescentintake