WesTCOAST CHILDREN’S CliNIC INTAKE INTERVIEW
Fax Form to 510-269-9031: Attn: Intake
Interview Date: / Referral Source:Phone: / Intake Clinician:
Client Name or ID#:
Gender: DOB: / SSN:
Medi-Cal # / Place of Birth
County:
State:
Address (if homeless, indicate):
Living Situation:
Family / Foster / Group / Relative Placement
Phone Numbers:
H:
C:
Other: / Marital Status:
Sexual Orientation:
Who is Legally Responsible?
Who has Legal Authorization to Consent for Treatment? / Race:
Cultural Needs:
Any Assisted Technology?
Languages:
Interpreter Needed: Yes No
What Language?
School:
Grade:
Teacher:
Phone: / CWW/Social Worker and ID #:
Phone Numbers:
C:
F:
Email:
Primary Caregiver:
Relationship to Client:
Languages:
Interpreter Needed: Yes No
What Language? / Biological Mother:
Address:
Phone:
Okay to Contact? Yes No / Biological Father:
Address:
Phone:
Okay to Contact? Yes No
Attorney:
Phone: / Probation Officer:
Phone: / Is the Client and Family Aware of Referral?
Yes No
Who is Living in the Home?
Stability of Current Living Situation: Stable Unstable Transitional
Length of Current Placement:
# of Past Placements and Reasons for Changes: / FAMILY HISTORY
Brief Psychosocial Family Hx
Any Mental Illness in the Family?
SERVICES REQUESTED:
[ ] Therapy: [ ] Individual or[ ] Family
[ ] Assessment: [ ] Full or [ ] Follow Up
[ ] FYDP:(Alameda County Foster Youth 16-18 Years OldOnly)
[ ] C-Change:(Sexually Exploited Minors)
PRESENTING PROBLEM [Note functional impairments]
Why Services Now?
SAFETY ASSESSMENT
Current Crisis?
Psychiatric Hospitalizations?
Safety Concerns? (i.e. Access to Weapons, Lethal Drugs) / RISK ASSESSMENT
0=No Evidence,1=History or Mild,2=Moderate,3=Severe
Suicide Risk: 0 1 2 3
History of Attempts: 0 1 2 3
Danger to Others: 0 1 2 3
Substance Use: 0 1 2 3
Depression: 0 1 2 3
Antisocial Behavior: 0 1 2 3
Caregiver Mental Health: 0 1 2 3
SCHOOL FUNCTIONING
Academic Progress
IEP or 504 Plan?
AB3632 / SDC / Spec Ed / RSP
Special Ed Contact Person / SOCIAL FUNCTIONING
Peer Relationships
Hx Client Violence / Property Destruction
Substance Use / Misuse
Criminal Justice Hx
MEDICAL HISTORY
Primary Care Physician:
Phone:
Date of Last Exam:
Major Illnesses, Injuries or Hospitalizations:
Current Eating / Sleeping / Energy
Any Drug /Food Allergies: Yes No
Current Medications (dosage, side effects and prescriber) / THERAPEUTIC SERVICES HISTORY:
WHERE / WHY / WHEN/ WITH WHOM?
How did client respond to service?
SERVICE LOCATION PREFERENCES
Where Would You Like the Services to Occur? Home School Office Community Other:
Able to Come to the Office?
Access to Private or Public Transportation?
Any Known Safety Issues in the Home or Community?
AVAILABLITY:
Preferred Days and Times for Services:
Mondays Tuesdays Wednesdays Thursdays Fridays Flexible
Times:
REQUEST FOR COMMUNITY-BASED SERVICES:
Reason for Request:
What are the Barriers to Clinic Services?
Willing to Attend Initial Meeting On-site?
INDIVIDUAL THERAPY REFERRAL
Why Individual Therapy Now?
What are the goals? / FAMILY THERAPY REFERRAL
Why Family Therapy Now?
What are the goals?
FYDP REFERRAL
What is the Emancipation Plan?
ILSP Involvement?
Case Management Needs
Appropriate for Group?
C-CHANGE REFERRAL [SEM/CSEC]
Hx of or Current Sexual Exploitation?
Does the Youth Have a Pimp?
Is the Youth Involved in Juvenile Justice System?
ASSESSMENT REFERRAL
*As of July 1, 2015 All Referrals for Psychological Assessments Must Receive Pre-Authorization from Alameda County Access at
1-800-491-9099.
Why is the Assessment Being Requested Now? What has Changed?
Who is Requesting the Assessment?
Can these Concerns be Addressed in Therapy?
Have the Ct been Tested Before? If, so When? Results?
Have they ever been Prescribed Psychotropic Medication? How did they Respond?
What is the Scope of the Requested Assessment? (i.e. Cognitive, Academic/Achievement, Personality or Emotional Functioning, or Comprehensive?)
What are the Assessment Questions? What Information is the Ct/Family Hoping to Gain from the Assessment?
Form Revised 12/1/2015