Child Client Intake Form Page 3
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8CHILD CLIENT INTAKE FORM – CONTINUED (Please print)
MEDICAL HISTORY: Please list any conditions, illnesses, treatments, or surgeries that might be relevant to reason for
seeking counseling:___________________________________________________________________________________________
Primary Care Physician’s Name: _____________________________________________ Phone #: ____________________________
Please list all current medications client is taking and the reasons for taking them:
Name of medications
Dose
Reason for taking
Prescribing Physician
Is client taking these medications according to the doctor’s recommendations? □ Yes □ No
COUNSELING HISTORY: If client has had any previous counseling, psychiatric treatment, substance abuse treatment, or
residential/in-patient care, please list the names of the therapists or programs. (Use the back if necessary.)
Therapist's Name or Program
Major Issue
Dates
Check off the symptoms or problems that you currently are or recently have experienced:
Stress / Anxiety / Worry / Fears
Parent/child conflict
Nervous movements or twitching
Seeing Things Others Don’t
Panic
Other Relational Problems
Depression / Cries a lot
Physical / Sexual Abuse
Hearing Voices
Apathy
Emotional / Verbal Abuse
Drug / Alcohol Use
Fatigue / Lack of Energy
Gender Identity Issues
Deliberately harms self
Loss of Appetite / Overeating
Bad Dreams
Angry / Excessively irritable
Trouble Sleeping / sleeps too much
Unwanted Memories
Frequent temper tantrums
Poor Concentration
Impulsive Behavior
Runs away from home
Feeling Worthless / Low esteem
Restless or hyperactive
Aggressive Behavior
Shyness / easily embarrassed
Obsessive Thoughts
Argues a lot / Lies / Steals
Loneliness
Compulsive Behaviors
Bullying or meanness to others
Clings to adults / overly dependent
Indecisiveness
Truant or suspended from school
Feels need to be perfect
Racing Thoughts
Disobedient at home / school
Learning disabilities
Grief
Cruel to animals/destroys property
Describe why you are coming to counseling and what you hope to gain from this process? (Use the back if necessary)
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
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