Child Intake Form printable pdf download

Stone Arch Psychology and Health Services

Ph. 612.886.2524

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Child Intake Form

Please fill out this questionnaire as completely as you can.

Child's Name__________________________________________ Today’s Date_______________ Gender Female Male

Date of Birth___________________ Birthplace____________________________________ Age_________ Grade__________



School___________________________________________________________________________________________________

Who Referred you to this evaluation?________________________________________________________________________

Describe your concerns____________________________________________________________________________________

When the concerns were first noticed_________________________________________________________________________

Your goals for the psychological services______________________________________________________________________

________________________________________________________________________________________________________

Family Members:

Mother:____________________________________ Age_______ Occupation:____________________ Ph.________________

Father:____________________________________ Age_______ Occupation:____________________ Ph._________________

Name

Relationship to Child

Age

Phone

Other Caregiver__________________________________________________________________________________________

Name

Relationship to Child

Age

Sibling__________________________________________________________________________________________________

Relationship Status of Biological parents______________________________________________________________________

If there were changes when did they occur?___________________________________________________________________

Custody Status of Parents__________________________________________________________________________________

Child's living arrangements?____________________________________________________________________

Stone Arch Psychology and Health Services Child Intake

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Child Intake Form