Child Intake Form Page 4
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8Client Name: ___________________________________________________________ Date: ___________________
Were there any complications during pregnancy (i.e., illness, injuries, hospitalization, etc.)?
Y
N
(Please describe) ___________________________________________________________________________________
Any complications during labor/delivery (i.e., premature, lack of oxygen, injuries to mother or child, incubator care,
infections, etc.?) Y N
(Please Explain) _____________________________________________________________
During the following periods did your child experience problems with any of these?
Infancy through First Year
Primary caregiver(s) during this time ___________________________________________________________________
Any changes in, or separation from, primary caregiver lasting more than 2 weeks________________________________
Did not enjoy cuddling______________________________________________________________________________
Was not calmed by being held or stroked________________________________________________________________
Difficult to comfort_________________________________________________________________________________
Colic_____________________________________________________________________________________________
Excessive restlessness________________________________________________________________________________
Excessive irritability_________________________________________________________________________________
Diminished sleep____________________________________________________________________________________
Frequent head banging_______________________________________________________________________________
Problems with nursing or taking bottle___________________________________________________________________
Constantly into everything____________________________________________________________________________
Other concerns _____________________________________________________________________________________
TODDLER (Second to Third Year)
Primary caregiver(s) during this time ___________________________________________________________________
Any changes in, or separation from, primary caregiver lasting more than 2 weeks ________________________________
Excessively active___________________________________________________________________________________
Cranky/irritable_____________________________________________________________________________________
Withdrawn/fearful___________________________________________________________________________________
Irregular patterns of sleep, appetite, habits________________________________________________________________
Discomfort with any auditory, tactile, visual stimulation ____________________________________________________
Was your child on time, early, or late in reaching developmental milestones? Please explain.
__________________________________________________________________________________________________
Has your child ever experienced traumatic experiences (such as changes, deaths in family, divorce, etc.)?
Please explain.______________________________________________________________________________________
__________________________________________________________________________________________________
Symptom
Frequently
Sometimes
Rarely
Never
Fails to give close attention to details or makes careless mistakes
Has difficulty sustaining attention in tasks or play activities
Doesn’t seem to listen when spoken to directly
Doesn’t follow through on instructions and fails to finish tasks
Has difficulty organizing tasks and activities
Avoids or is reluctant to engage in tasks that require sustained effort
Loses things necessary for tasks or activities
Is easily distracted by external stimuli
Is forgetful in daily activities
Fidgets with hands or feet or squirms in seat
Leaves seat in situations in which remaining seated is expected
Runs about or climbs excessively in situations in which it is inappropriate
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