Child Intake Documents I And Ii printable pdf download

Child Intake Documents I And Ii

Child Intake Documents I and II

Child and Family History Forms completed by: ( ) Parent ( ) Foster Parent ( ) Grandparent

Child’s Name: _________________________________________________ DOB:_____________________

Are you a divorced/single parent? ( ) yes ( ) no If yes, does the child have visitation with the other parent?_____

Gender: ( ) male ( ) female Grade: ________ Name of School:___________________________________

Home Address:______________________________City:__________________________Zip ____________

Phone: (H)________________________(W)_________________________(Cell)______________________

Parent’s preferred email address: _____________________________________________________________

Dr. McDonald may leave messages at: ( ) Home ( ) Work ( ) Cell ( ) Text ( ) Email

Emergency Contact: ___________________________Phone: _________________Relationship: ___________

Number of siblings in the home:_________________

Child’s main reason for visit:

How long has this problem persisted?

Has your child been to counseling/therapy in the past? ( ) yes ( ) no

If yes, was it helpful? ( ) yes ( ) no

Has your child had inpatient mental health treatment/hospitalization: ( ) yes

( ) no

If yes, please give name of

facility/therapist, presenting issues and outcome of treatment:

What are your child’s interests?____________________________________________________________________

What are your child’s strengths?___________________________________________________________________

What are your child’sweaknesses?__________________________________________________________________

Child Intake Documents I And Ii