Therapy
Individual
Couples
Family
Child issues
Group
Anxiety Clinic
Behavior Medicine
(i.e., pain, chronic illness)
Autism Clinic
Assessment
Career
Academic
Personality
Other
How did you hear about us?
Insurance status*
Private
VCC/MCV code
Medicare/Medicaid
None
School information
Name of child’s school*
Address*
Child’s current grade placement*
Teacher*
Name*
Date of birth
(mm/dd/yyyy)*
Age*
Address*
City*
State*
ZIP code*
Telephone number(s)*
(###) ###-####
Preferred
Home
Work
Cell
Relationship status*
Single
Married
Divorced
Separated
Widowed
Other
Work status
(check one)*
Unemployed
Employed full-time
Employed part-time
Student
Disabled
Other
Occupation*
Total family income
(before taxes)*
/year
Name
Date of birth
Age
Address
City
State
ZIP code
Telephone number(s)
(###) ###-####
Preferred
Home
Work
Cell
Relationship to child
Medical information
Has your child experienced any of the following medical problems? (Check all that apply.)*
Medical hospitalization
Psychological hospitalization
Surgery
Chronic illness
Asthma
Head injury
High fever
Convulsions/seizures
Eye/ear problems
Serious accident
Serious illness
Hearing problems
Allergies
Loss of consciousness
Other
Not applicable
Please describe any serious or chronic medical or physical problems.*
Not applicable
Please list child’s current and past medications. Please include (a) name of medication (b) dates taken (c) dosage (ex – 10mg twice daily) (d) name of prescribing doctor: *
Not applicable
Primary Care Medical Provider
Name
Phone number
Child history
What are some of the feelings or thoughts your child is experiencing? (Check all that apply.) *
Anger
Depression
Anxiety/panic
Alcohol/drugs
Fears
Crying all the time
Acting out in school
Learning problems
Confusion
Relationship issues
Life adjustment/enhancement
Other
Not applicable
How long has he/she been feeling this way? *
In your own words, please describe briefly the problem your child is experiencing.*
Has anything happened recently or changed in his/her life that might be related to these feelings? (Check all that apply.) *
Recent loss or death of a close friend/family member
Change or loss in work or living situation
Other
Not applicable
Has she/he felt this way in the past?*
Yes
No
Not applicable
If yes, please describe.
Has your child experienced any of the following problems at school? (Check all that apply.)*
Fighting
Lack of friends
Drugs/alcohol
Detention
Suspension
Learning disabilities
Poor grades
Gang influence
Incomplete homework
Behavior problems
Poor attendance
Other
No problems
Behavioral excesses*
What does your child currently do too often, too much, or at the wrong times that gets him/her in trouble? Please list all the behaviors you can think of.
Behavioral deficits*
What does your child fail to do as often as you would like, as much as you would like, or when you would like? Please list all the behaviors.
Treatment goals*
Which of your child’s problem behaviors do you want to see addressed?
Has your child had counseling before?*
Yes
No
Has your child ever experienced any type of abuse (physical, sexual or verbal)?*
Yes
No
If yes, please describe.
Has your child ever made statements of wanting to hurt him/her self or seriously hurt someone else? Has he/she ever purposely hurt himself or another?*
Yes
No
If yes, please describe.
Has your child ever experienced any serious emotional losses (such as a death of or physical separation from a parent or other caretaker)?*
Yes
No
If yes, please describe.
Has he/she ever been charged with or convicted of a crime (misdemeanor or felony)?*
Yes
No
If yes, please describe.
Do you have any other concerns about your child or your family that you have not mentioned yet?*
Yes
No
If yes, please describe.
Primary caretaker/guardian history
Have you ever been hospitalized for psychological reasons?*
Yes
No
If yes, please explain for what and when.
Are you currently taking any medications, such as for anxiety, depression, ADHD, etc.?*
Yes
No
If yes, please include names and dosage(s).
How many alcoholic drinks do you have in a typical week? (Check one.)*
None
0-3
4-7
8-11
12-15
more than 15
Do you use any street drugs or medications prescribed for someone else?*
Yes
No
Are you ever involved in physical fights with other people?*
Yes
No
Are you currently, or have you ever, been involved in the legal system?*
Yes
No
Has your family ever been involved with Child Protective Service?*
Yes
No
If you have children, have you ever lost custody of your children?*
Yes
No
Do not have children
Thank you for taking the time to fill out our application. An intake coordinator will be in touch with you soon to continue the processing of your application.
