Minor Intake Form

Minor Intake Form

Professional Counselors of Lansing

913 W. Holmes Road, Ste #A125

Lansing, MI 48910

Office Number (517)394-0929

Fax Number (866) 268-7774

Please print out this form and complete it prior to your child’s/minor’s first session, or allow yourself thirty minutes prior to your appointment to complete this form in the office. Please answer all questions to the best of your ability. In the event that you need assistance in completing this form, please let one of our staff members know and we will be more than willing to assist you. This information is kept confidential, and will only be shared with your signed permission.

Date: ______

Child’s/Minor’s Name:______

Last Name First Name Middle Initial

Date of Birth: ______Age:______SSN (last FOUR only):______

Please Circle Gender: Male Female

Name of parent/guardian

Name:______

Last Name First Name Middle Initial

Current Address:______

City State Zip Code

Home Phone: ______May we leave a message ? Yes No

Cell/Other Contact: ______May we leave a message? Yes No

(Optional) Email address:______May we email you? Yes No

Please consider the risk of confidentiality

Would you like reminders by: Phone Email Text Message

In case of emergency we have your permission to contact:______

Name of Contact Person and Relationship

Contact Number (s):______

Cell Alternate Number

Please circle all that applies:

Your child/minor resides with:

Mom and Dad Mom and Stepparent Dad and Stepparent Adoptive Parent (s)

Mom Foster Parent (s) / Parental Grandparent (s) Family Friend
Dad Sibling / Maternal Grandparent (s) Other Relative
Mom and Mom Dad and Dad
Please circle all that applies: / Mom and Significant other Dad and Significant other
Do you have joint custody? / Yes or No

Do you have joint legal/physical custody? Yes or No

Total number of children part of the blended family? ______

Ages: ______

ACADEMICS

Does your child/minor receive Special Education Services at school? Yes or No

If yes, what is your child’s/minor’s disability? ______

Please provide the name of the school your child’s/minor’s attends:

______

Please list the names of the teachers your child/minor currently has and the core subjects taught.

______

Name of Teacher Subject

______

Name of Teacher Subject

______

Name of Teacher Subject

______

Name of Teacher Subject

______

Name of Teacher Subject

______

Name of Teacher Subject

What is your child’s/minor’s average current grade or GPA? ______

Please circle:

Has your child/minor ever been retained? Yes or No

If so, when and what grade? ______

Please list or explain any additional information concerning your child’s/minor’s academic progress or concerns:

______

______

______.

PSYCHOLOGICAL/ HEALTH/SOCIAL HISTORY AND FAMILY HISTORY:

Please circle yes or no:

Has your child/minor ever had psychotherapy? Yes No ______

Name of therapist

Is your child/minor currently receiving psychiatric services, professional counseling or psychotherapy? Yes No

Is your child/minor currently taking prescribed psychiatric medication (antidepressants or other medications)?

Yes No If yes, please list:______

If no, has your child/minor ever been prescribed psychiatric medication?

Please list: ______

Please circle yes or no:

Was your child/minor born prematurely? / Yes No
Has your child/minor experienced any development delays? / Yes No
Does your child/minor make friends easily? / Yes No
Is your child/minor withdrawn in social situation? / Yes No
Does your child/minor have a good relationship with family members? / Yes No
Does your child/minor have any anger issues? / Yes No
Has your Child’s/Minor ever been abused physically / Yes No

Has your Child’s/Minor ever been abused mentally Yes No

Has your Child’s/Minor ever been abused emotionally? Yes No

Has your Child’s/Minor ever been bullied? Yes No

Has your Child’s/Minor ever experienced a traumatic event? Yes No Please indicate if your CHILD/MINOR has ever experienced the following by circling yes or no:

Alcohol/Substance Abuse Yes No

Body Image Problems Yes No

Compulsive Behaviors Yes No

Eating Disorder Yes No

Extreme Anxiety Yes No

Extreme depressed mood Yes No

Frequent Body Complaints Yes No

Hallucinations Yes No

Homicidal Thoughts Yes No

Irrational Thoughts Yes No

Panic Attacks Yes No

Phobias Yes No

Rapid Speech Yes No

Sleep Disturbances Yes No

Suicide Attempts Yes No

Unexplained losses of time Yes No

Unexplained memory lapses Yes No

Wild Mold Swings Yes No Please indicate the FAMILY member (s) affected by disorder by circling yes or no and listing family member and their relationship with child/minor:

Mental History / Family Member
Alcohol/Substance Abuse / Yes No / ______
Anxiety Disorder / Yes No / ______
Bipolar Disorder / Yes No / ______
Depression / Yes No / ______
Eating Disorders / Yes No / ______
Learning Disabilities / Yes No / ______
Panic Attacks / Yes No / ______
Post-Traumatic Stress / Yes No ______
Schizophrenia / Yes No ______
Suicide Attempts / Yes No ______
Trauma History / Yes No ______

1.How is your child’s/minor’s overall physical health? please circle

Poor Unsatisfactory Satisfactory Good Very Good

2.Please list any persistent physical symptoms or health concerns.

______

______

3.Is your child/minor having any problems sleeping problems? Yes No

If yes, please circle what applies

Sleeping too little Sleeping too much Poor quality sleep Disturbing dreams

Other: ______

HEALTH AND SOCIAL INFORMATION CONTINUED:

4.Please indicate any physical/social activities your child/minor is involved in and how often.

______

______

Please circle what applies:

5.Does your child/minor have any difficulty with appetite or eating habits? Yes No If yes, check where applicable: Eating Less Eating More Binging Restricting

6.Has your child/minor experienced significant weight change in the last 2 months? Yes No

7.Does your child/minor regularly indulge in alcohol? Yes No

8.In a typical month, how often does your child/minor have 3 or more drinks in a 24 hour period?______

9.How often does your child/minor engage in recreational drug use? Daily Weekly Monthly Rarely Never

10.Has your child/minor had suicidal thoughts recently? Never Rarely Sometimes Frequently

11.Has your child/minor had any suicidal thoughts in the past? Never Rarely Sometimes Frequently

12.Has your child/minor ever attempted suicide? Yes or No

13.Has your child/minor ever engaged in self-harm? Yes or No

14.Is your child/minor in a romantic relationship? Yes or No

15.If yes, how long has your child/minor been in this relationship? ______

16.Is the relationship healthy? Yes No

17.In the last year, has your child/minor experienced any major life changes or stressors? Yes No

If yes, please explain______

______

OTHER INFORMATION:

What would you like your child/minor to accomplish during therapy?

______

______

What do you consider your child’s/minor’s strengths? ______

______

______

______.

What do you consider your child’s/minor’s weaknesses? ______

______

______

______.

Does your child/minor know why you are requesting therapy for him/her? Yes No

As the parent/guardian of this child/minor, do you have any questions or concerns?

______

______

______

______.

I, the parent/guardian of ______provided the above information on

Name of child/minor

behalf of my child/minor to the best of my ability and knowledge.

______

Parent/Guardian Signature Date

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