Counseling Services, Inc.
CHILD INTAKE FORM
Thank you for taking the time to complete this intake form. The information which you provide here helps
us to do a thorough evaluation of your child more efficiently. Please complete all items if possible. If you
have any questions, please ask.
Name of person completing this form: _______________________________________Date:___________
Child’s name:_______________________________________________________________________________
Birth date_________________________________________ Current age_____________ Sex: M
F
Home address_______________________________________________________________________________
Home phone number________________________________________________________________________
Child’s school___________________________________________ Child’s teacher ____________________
Grade_________________ Special placement (if any) __________________________________________
Who referred you to Counseling Services, Inc._________________________________________________
Briefly describe the child’s problems for which you would like help. Please be as specific as possible.
1.___________________________________________________________________________________________
2.___________________________________________________________________________________________
3.___________________________________________________________________________________________
FAMILY MEMBERS:
Name
Age
Occupation/Grade in School
Parent/Guardian
_________________________________________________________________________
Parent/Guardian
_________________________________________________________________________
Siblings
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Others
_________________________________________________________________________
_________________________________________________________________________
FAMILY HISTORY
Have any of the child’s blood relatives (biological parents, grandparents, siblings, aunts, uncles, or close
cousins) experienced the following? Please specify which relative.
_______Reading problems____________________________________________________________________
_______Attention problems___________________________________________________________________
_______Hyperactivity_________________________________________________________________________
_______Developmental disorders/mental retardation__________________________________________
_______Addiction to alcohol or other drugs____________________________________________________
_______Severe depression____________________________________________________________________
_______Other significant mental illness or disorder______________________________________________
_______Genetic syndromes___________________________________________________________________
_______Other________________________________________________________________________________
CURRENT FAMILY STRESSORS
Have any of the following stressful events occurred within the past 12 months?
_________parents divorced or separated
_________family accident or illness
_________death in family
_________parent changed job
_________changed schools
_________family moved
_________family financial problems
_________Other (please specify)________________