Counseling Intake Form (Minors)

Please complete the form below if you’re interested in my Counseling Services!

Child/ Adolescent Name *

Child/ Adolescent Date of Birth *

Child/ Adolescent Current Grade *

Child/ Adolescent Current Name of School *

Parent/ Guardian Phone Number *

Parent/ Guardian Mailing Address *

Mother's Name *

Mother's Highest Grade Level *

If Mother is deceased, date

Father's Name *

Father's Highest Grade Level *

If Father is deceased, date

If the Child’s parents are not currently married, please describe below (dates of adoption, divorce, remarriage, names of step-parents, and/or other relevant information): *

Brothers/ Sisters *

If yes, please share

Are both parents in agreement with bringing him/ her for counseling? *

Please describe any recent changes for your family (births, deaths, moves, accidents, etc): *

Your Relationship to Child *

Reason for Treatment *

Any Previous Treatment? *

If yes, please explain

How does your child/ adolescent feel about counseling at this time? *

In what way would you like counseling to help your child/ adolescent? *

What family members are likely willing to participate in your child’s counseling? *

Did your child generally meet developmental milestones (i.e., walking, talking, etc.) on time? *

Please describe any difficulties your child/adolescent is having in school. *

Has your child ever been psychologically tested? *

Does your child/ adolescent attend church? *

What role does spirituality play in his/ her life? *

On-going Medical Conditions *

If yes, please explain

Is your child/adolescent taking any prescription medication? *

Any Side Effects? *

If yes, please explain

Has your child had a hearing exam? *

Has your child had an eye exam? *

Were any problems discovered for either of the above? *

If yes, please explain

Has your child used drugs or alcohol? *

Family history of substance abuse? *

Please share any areas of concern *

Please describe your daughter/son in a few sentences (areas of relative strength or giftedness, challenges, etc.) *

Is there anything that would be good for your counselor to know? *

Have you thoroughly reviewed the information above? *