Child's/Teen's Preferred Name or Nickname

Pronouns your child/teen uses

She/her, he/him, they/them, etc.

Names of Parents or Legal Guardians and Names and Ages of Others in the Household

Parent or Legal Guardian Email Address

Emergency Contact

Please identify the name of an emergency contact and their relationship to the child or youth.

Name of School and Grade

If attending, please identify school name and grade level. If not, please indicate reason for not attending.

Child or Youth's Favorite Hobbies

Is your child involved with special education?

What does your child or youth do really well?

List 1-3 strengths.

Why are you seeking counseling for your child or teen?

Any other concerns not listed above?

Any developmental concerns?

Was their anything unusual or atypical about child's or youth's birth, developmental history, developmental milestones, etc.?

Does your child or youth have another provider involved (i.e. psychiatrist, other counselor, alternative health provider, etc.)?

List name(s) and how they are helping.

Does your child or youth take any medications?

If so, please list the medications and their purpose.

Has the child/youth experienced any form of abuse (ex. sexual abuse, physical abuse, verbal abuse, neglect, medical abuse, etc.)?

If so, please describe the type of abuse, when the abuse occurred, and who perpetrated the abuse (if known). Please indicate if the abuse has already been reported to Child Welfare and/or authorities.

Child or Youth Intake Form