Child Intake Form (Page 5 of 8) in pdf

Client Name: ___________________________________________________________ Date: ___________________

Has difficulty playing or engaging in leisure activities quietly

Is “on the go” or acts as if “driven by a motor”

Talks excessively

Blurts out answers before the questions have been completed

Has difficulty awaiting turn

Interrupts or intrudes on others (e.g., butts into conversations or games)

Loses temper

Argues with adults

Actively defies or refuses to comply with adults’ requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehavior

Is touchy or easily annoyed by others

Restricted range of affect (i.e., unable to have loving feelings)

Sense of foreshortened future

Difficulty falling or staying asleep

Irritability or outbursts of anger

Difficulty concentrating

Hypervigilance

Exaggerated startle response

Excessive distress when separation from home or loved ones is anticipated

Excessive worry about losing, or harm happening to, a loved one

Excessive worry that some bad event will lead to separation from loved ones

Reluctance of refusal to go to school or elsewhere because of fear of

separation

Excessive fear to be alone at home or elsewhere without loved ones

Reluctance or refusal to go to sleep without being near loved ones

Nightmares or night terrors

Complaints of physical symptoms when separation occurs or is anticipated

Substance use resulting in a failure to fulfill major obligations at school or

work

Substance use in situations in which it is physically hazardous (i.e., driving)

Substance use related to legal problems

Substance use despite recurring social or interpersonal problems

Parent Information:

Please describe your relationship (both positive and negative) with your child.

__________________________________________________________________________________________________

Please describe the other parent’s relationship with your child.

__________________________________________________________________________________________________

Please describe your communication with your child.

__________________________________________________________________________________________________

Please rate and describe your stress level with your child. (1=low to 10=high)

__________________________________________________________________________________________________

Please list any parenting challenges (anxiety, work stress, depression, single parent, etc.)

__________________________________________________________________________________________________

Child Intake Form Page 5

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