Child Client Intake Form (Page 2 of 8) in pdf

Child Client Intake Form Page 2

CHILD CLIENT INTAKE FORM – CONTINUED (Please print)

Does the family regularly attend a church, synagogue, or other religious institution? □ Yes □ No

If yes which one? _______________________________________________________________

Grade: ____________ School: __________________________________ Teacher: ________________________________________

Academic problems: __________________________________________________________________________________________

If parents are divorced, when was the divorce final? _________________________ What is the custody/visitation schedule for client?

____________________________________________________________________________________________________________

Siblings and step-siblings:

Name

Sex

Age or yr. of death

Relationship to client

Living with whom?

Who else lives with you? _______________________________________________________________________________________

Please list client’s stepparents, or other family members who have a significant effect on client’s life

Name

Sex

Age or yr. of death

Relationship to client

Describe him/her

□ Yes

□ No

Has anyone in your family been treated or hospitalized for substance abuse or mental health issues?

If yes, explain: _______________________________________________________________________________________________

____________________________________________________________________________________________________________

□ Yes

□ No

Is client currently experiencing any suicidal thoughts?

□ Yes

□ No

Has client experienced suicidal thoughts in the past?

□ Yes

□ No

Has client attempted suicide in the past?

□ Yes

□ No

Is client currently experiencing any violent or homicidal thoughts?

Child Client Intake Form Page 2