Christian Counseling Services
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1 1 Christian Counseling Services Minor Intake Assessment and Consent Form *Please complete this form before the first session General Information: Client s Name: DOB and Age: Gender: Male ( ) Female ( ) Full Address: Parent/Guardian Name (#1): Relationship: Parent/Guardian Name (#2): Relationship: Parent s Phone Number: (CELL / HOME) Is it OK to leave messages?: Text (YES / NO) Voic (YES / NO) Parent s Address: Custody terms (if applicable)*: NA ( ) * If there is a formal custody arrangement, please bring the appropriate court documentation to the first session. Referral Information: How did you hear about Christian Counseling Services? Type of services needed: Child/Adolescent Therapy ( ) Family Therapy ( ) Medical Referral ( ) Who completed this packet?: Parent ( ) Foster Parent ( ) Legal Guardian ( ) Client ( ) Other ( ) Please describe the main problem/reason for seeking therapy: What changes or improvement is expected after treatment?: Emergency Contact: Name: Relationship: Phone Number Is this person allowed to pick up the client? Yes ( ) No ( ) I attest that the information contained in this packet is true and correct to the best of my knowledge: Parent/Guardian Printed Name: Parent/Guardian Signature: Date:
2 2 Presenting Problem Checklist (Please indicate all concerning behaviors): Issue Past Present Issue Past Present Crying, sadness, depression Temper tantrums/outbursts Lost enjoyment in usual activities Irritability/anger Tiredness/fatigue Excessive arguing Anxiousness/nervousness Disobedience/defiance Panic attacks Intentionally annoying to others Excessive worry Gets annoyed easily Low self-esteem Aggressive behavior/fighting Withdrawn Impulsive/acts without thinking Change to sleep patterns Negative thoughts Nightmare/night terrors Blames others/refuses responsibility Sleepwalking Refusal to complete chores Poor bladder control/bedwetting Intentionally hurts people or animals Change in eating patterns/appetite Intentionally destroys property Preoccupied with weight/size Uses inappropriate language/swears Extreme weight loss or gain Inappropriate sexual behavior Usual fears or phobias Accesses pornography Headaches/stomachaches Threatened/attempted running away Twitches or involuntary tics Sneaking out Hallucinations Academic decline Has rituals, habits, superstitions Lack of motivation Repeats unnecessary behaviors Easily distracted Poor hygiene or self-care habits Trouble concentrating Self-injury Fidgeting/excessive activity Homicidal thoughts Cannot complete tasks Preoccupied with death Disruptive Suicidal thought(s)/attempt(s) Questioning sexual orientation Lying Physical Abuse Stealing Sexual Abuse Problem with authority Emotional/Mental/Verbal Abuse Legal issues Drug/alcohol use Other behavioral or emotional concerns/symptoms: Please describe the most important/distressing symptoms (Severity = 1 10): Symptom #1: Severity: Frequency: Duration: Symptom #2: Severity: Frequency: Duration: Symptom #3: Severity: Frequency: Duration: Symptom #4: Severity: Frequency: Duration:
3 What are some of the client s strengths?: What are some of the client s weaknesses?: If abuse was indicated, please provide additional details (dates, locations, perpetrators, impact to client/family, action taken): NA ( ) If self-harm, suicide, or homicide was indicated, please provide additional details (threat, victim, action taken, timeline, etc.): NA ( ) Does the client have a current intent/active plan for harm to themselves or someone else? Yes ( ) No ( ) 3 Developmental History: Please indicate any complications related to the pregnancy, labor, and birth of the client: Mother used drugs Health problems during pregnancy Premature birth Mother used alcohol Problems with labor Admitted to NICU Mother was on bed rest Problems with delivery Born with cord around neck As an infant/toddler, please indicate any difficulties the client experienced in the following areas: Eating/feeding self Turning over Crawling/walking Toilet training Language development Sleeping thought the night Following basic commands Separating from parents Interacting with other children Please describe: NA ( ) Please describe any major health issues the client had up to 5 years old (such as seizures, severe colic, organ defects, injuries, major infections, etc.): NA ( ) Issue Age Outcome Was the client breastfed? Yes ( ) No ( ) Is the client a multiple? Yes ( ) No ( ) Please rate the client s activity level (up to age 5): Very active ( ) Active ( ) Average ( ) Less active ( ) Not active ( ) Approximately how long did toilet training take?:
4 4 Family History: Please indicate all members in the client s immediate family: Name Age Relationship In the home? (Y/N) Occupation/Grade Current living situation: Previous living situation (past year): Does the client live in a single parent household?: Yes ( ) No ( ) Does the client live with a blended family?: Yes ( ) No ( ) Specify the overall level of family conflict: High ( ) Moderate ( ) Low ( ) How well does the client get along with his/her sibling(s)? With which family member is the client closest?: Which family relationships are tense/distant/negative?: Are there any current marital problems that could be affecting the client?: Yes ( ) No ( ) If yes, please describe: What are the family s strengths? Is there any history of the following in the past two biological generations (please continue on back if needed)?: Issue Who Comments Mental illness Abuse Addiction Learning disabilities Birth defects Significant legal issues What type of discipline is used at home? Type Frequency Effectiveness (1-10) Administered by: Verbal reprimands Time out/isolation Removal of privileges Rewards Physical punishment/spanking Natural consequences Threats/Warnings Giving in or avoiding confrontation Emotion coaching
5 5 Please indicate the following about the family s dynamics: Our family is warm and loving Yes ( ) No ( ) Family members are respectful to one another Yes ( ) No ( ) Our home is very chaotic Yes ( ) No ( ) Our family feels connected Yes ( ) No ( ) Our home has a lot of conflict Yes ( ) No ( ) How has the family been impacted by the client s problem(s)?: In what ways is the family willing to be involved in the client s treatment?: What is the role of any other family member(s) in the client s problem(s)?: Social History: Please indicate the items that describe the client in social situations: Prefers to be alone Few friends/feels lonely Shy/withdrawn Many friends/popular Outgoing/friendly Poor personal boundaries Gravitates towards problem kids Has inappropriate interactions with others Is oversensitive/easily offended Gets teased/bullied Physical fights with others Teases or bullies others Poor peer relationships Frequent conflict with others Difficulty sharing or negotiating with others Tends to be demanding or bossy Makes friends easily Shows good manners/respects others Please describe the client s personality with a few adjectives: Is the client generally comfortable in social situations?: Yes ( ) No ( ) Has the client completed puberty? Yes ( ) No ( ) Please describe any age-inappropriate sexual activity or behaviors that have been observed: Client relationship status: Single ( ) In a relationship ( ) It s complicated ( ) NA ( ) If a relationship was indicated, please indicate length: Is the client sexually active? Yes ( ) No ( ) Not sure ( ) If yes, are birth control methods being utilized? Yes ( ) No ( ) Not sure ( ) Does the client show any signs of sexual orientation or gender identity issues: Yes ( ) No ( ) If yes, please explain:
6 Is there any other important information regarding the client s sexual maturation, activities, or health? 6 Medical/Treatment History: Please indicate the client s major health problems or surgeries: Condition Yes Age Details Serious infections Major surgeries Extended hospitalizations Significant injuries Allergies Drug abuse/addiction Sexually transmitted diseases Chronic illnesses Genetic disorders Other Comments: Please indicate any regular medication the client is taking (especially psychiatric medication): Medication Dose/Duration Purpose Has the client ever had mental health treatment before? (Please continue on the back, if needed): Provider Reason/Services Outcome Has the client ever been hospitalized for psychiatric issues: Yes ( ) No ( ) Has the client ever been admitted for residential treatment: Yes ( ) No ( ) Has the client ever been seen by a psychiatrist? Yes ( ) No ( ) When was the last time that the client was assessed by a General Practitioner? Does the client complain of frequent aches or pains? Yes ( ) No ( ) If yes, please describe:
7 School/Academic History: Name of School: Institution Type: Grade (current or highest completed): Average performance (grades A-F): Does the client have a diagnosed learning disability?: Yes ( ) No ( ) If yes, please specify: Treatment/Action Plan: If yes, does the school have an established Individual Education Plan (IEP)?: Yes ( ) No ( ) If yes, what are the current accommodations?: Has the client ever attended a special education program?: Yes ( ) No ( ) If yes, please describe type and duration: Please check any significant educational issues: Issue Yes Grade Yes Grade Disruptive in class Tutoring needed Oppositional with teachers Detention Failure to complete or submit work Suspension/Expulsion Refusal to go to school Poor relationships with teacher(s) Excessive absences/truancy Repeated grades 7 Please clarify: Please summarize the client s general progress in school (including academic performance, social behaviors, testing, significant accomplishments, extracurricular activities, etc.): Current Stressors: Please indicate any major changes that have occurred in the family/home environment in the last 12 months: Stressor Impact (1-10) Stressor Impact (1-10) Financial problems Mental illness diagnosed Recent move/frequent moving Major physical illness/hospitalization Divorce/Separation Legal problems Remarriage Onset of drug or alcohol use Separation from siblings Probation Job changes Loss of relative/friend/pet Significant change in routine Observed or experienced abuse Marital problems/parental conflict Housing problems Adoption/foster care Custody battle Please clarify:
8 8 Christian Counseling Services Consent for Treatment of a Minor * To be signed by all parents and/or legal guardians. I/we (, the parent(s)/legal guardian(s) of (age ), (hereinafter referred to as the minor ), give authorization and consent for Christian Counseling Services to provide counseling to the minor. This authorization and consent is given with my understanding that, although rare, there are potential risks associated with counseling children under 18. I/We fully understand these potential risks and choose to allow the minor to participate in counseling. I/We release Christian Counseling Services from any liability for discomfort, related to counseling services provided. I/We have read and fully understand this authorization and release form. I/we understand that this form should not be signed if I/we do not fully understand or if all my/our questions have not been answered satisfactorily. Printed name: Printed name: Signature: Signature: Date: Date:
Name Age Relationship to patient
Clackamas Pediatric Clinic Oregon Pediatrics Meridian Park 8645 SE Sunnybrook Blvd #200 19260 SW 65 th Ave #275 Clackamas, OR 97015 Tualatin, OR 97062 (503) 659-1694 (503) 691-2519 Oregon Pediatrics Happy
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