Child Intake Form Page 3
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8Client Name: ___________________________________________________________ Date: ___________________
Family Atmosphere (circle the number that best describes how you view your current family)
Very Lenient
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Very Strict
Very Relaxed Environment
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Very Tense Environment
Very Unstructured
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Very Structured
Few Expectations
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High Expectations
Consistent
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Inconsistent
Parent Assessment of Child:
List the child’s strengths:
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
List the child’s areas needing improvement:
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
List the child’s main difficulties in school and/or daycare:
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
List the child’s main difficulties at home:
1.________________________________________________________________________________________________
2.________________________________________________________________________________________________
3.________________________________________________________________________________________________
Briefly describe the child’s friendships: __________________________________________________________________
__________________________________________________________________________________________________
Briefly describe the child’s hobbies and interests: __________________________________________________________
__________________________________________________________________________________________________
Describe how the child is disciplined: ___________________________________________________________________
__________________________________________________________________________________________________
For what reasons is the child disciplined: ________________________________________________________________
__________________________________________________________________________________________________
Briefly describe the child’s way of expressing the following emotions or behaviors:
1. Anger: __________________________________________________________________________________________
2. Happiness: ______________________________________________________________________________________
3. Sadness: ________________________________________________________________________________________
4. Anxiety: ________________________________________________________________________________________
Developmental History:
Pregnancy, Labor and Delivery
Duration of Pregnancy _____________ Did the mother smoke?
Y
N
(if yes, how many packs per day?) _______
Was there any drinking or drug use by mother during this time?
Y
N
(Please describe fully)_______________________________________________________________________________
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