Minor Child Intake Form

Client Name: ______Date: ______

Client Date of Birth: ______Age: ______

Name of Parent/Guardian/Responsible Party (circle one): ______

*Please allow your child to complete as much of this form as appropriate given their age/ability level. Questions are written as if the minor child will be completing the form.

Reason For Seeking Services:

Briefly describe what difficulty led you to seek counseling: ______

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How long has this been a problem for you: ______

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What do you hope to accomplish or change in therapy: ______

______

Have you had any problems at work/school/home as a result of this problem? If yes, describe: ______

______

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On a scale of 1-10, how would you rate your distress (1 is low, 10 is very high): ______

Please circle any significant life events:

Change of ChangeMoved to a new placeDeath in the family or close friend

Divorce/separationSerious injury/illnessSerious illness in family/close friend

Frightening EventsOther (explain below)None of the above

Comments: ______

Health History

Do you have any physical health problems (explain): ______

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Please list any major medical procedures (and year of procedure): ______

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Do you use tobacco products: YesNo

Do you use alcohol:YesNoIf yes, how often: ______

How much at each occurrence: ______

Do you use any illegal substances:YesNoIf yes, what type(s): ______

How much at each occurrence: ______

Any significant weight change in the last 6 months: YesNo

Any significant change in appetite in the past month:YesNo

Please list any current prescription or daily over the counter medications:

Medication / Dosage / How long (approx.) / Purpose of medication

Behavioral Health Information

Please list any prior mental health or alcohol/drug treatment:

Dates / Provider/Agency Name / Purpose of treatment

Is there any family history of mental health problems or treatment (list problem and relationship):______

______

Is there any family history of alcohol or other drug abuse (list problem and relationship): ______

______

Have you ever experienced (circle all that apply):

Physical AbuseRape/Sexual AssaultEmotional Abuse

Sexual AbuseDomestic ViolenceWitnessed any of the above

Other significant trauma

This will be addressed more fully, as you are comfortable, with your individual psychologist.

Employment

Are you currently employed outside the home?YesNo

What type of employment and how long have you been with your current employer: ______

______

Legal

Have you been involved in any legal matters in the past or in the present?YesNo

Please explain: ______

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Cultural / Ethnic / Spiritual / Sexual

Cultural/ethnic/racial issues that we should consider or address: ______

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Sexual orientation or gender identity issues that we should consider or address: ______

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Religious/spiritual issues that we should consider or address: ______

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Print Parent/Guardian Name: ______

Parent/Guardian Signature: ______Date: ______

Western Ohio Psychological Services LLC Staff Signature: ______