Biographical History Form Child/Adolescent
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1 Biographical History Form Child/Adolescent First Name: Middle Name: Last Name: Address: Child s Age: Child s DOB: / / Male Female Today s Date: / / Mother/Guardian: Cell #: Home#: Father/Guardian: Cell #: Home#: Occupation: Business: Occupation: Business: Languages Spoken: English Spanish Hebrew Creole French Other Primary language at home: Ethnicity: White/Caucasian African/American Latino/Hispanic Native American Jamaican Haitian Multiracial Other The parents: Marriage Intact Separated Divorced Remarried Deceased How long? Who does the child live with?: Family Shared Custody Single Parent Guardian Other Referred by: Was/Is your child?: Prenatal/Neonatal: Initial Medical: School Physician Therapist Insurance Co. EAP Family Member Friend Internet Other Born Natural Born C-Section IVF Birth Complications Adopted Foster Child Other Healthy Mom Healthy Infant High Risk Preg. Labor Induced Premature NICU Jaundiced Other No Concerns Colicky Speech Delays Hearing Problems Allergies Chronic Illness Other
2 When a baby: Smiled often Easy to soothe Adapted well Difficult to soothe Excessively cried Other What Age? Sat alone Crawled Walked Combined words Toilet Trained Dressed Self Homework Alone _ Concerns During infancy: As a toddler: Compliant Quiet Stubborn Independent Aggressive Friendly Shy/Timid Affectionate Other Kindergarten began: On Time Delayed Repeated Other Current School information: Public Private Grade School Name When with peers: Leader Follower Shy/Timid Friendly Aggressive Other My child has been: Bullied by peers Abused Had losses Sibling rivalry Skipping school Other Developmental: Educational: Behavioral: Emotional: Speech Delay Diff. Hearing Language Delay Visual Problems Emotional Delay Social Problems Other Reading Issues Writing Problems Math Challenges ADHD symptoms Current IEP Accommodations Other Biting Hitting Tantrums Bullying Rebelling Fighting Stealing Other Anxiety Frustration Problems Over-Reactive Over-Sensitive Diff. Adjusting Diff. Sharing Other Current Time: Play Alone Play w/ Sibling Play w/peers Play w/adults Which one is most frequent? Current Activities: Child s Substance Use (past 30 days): Caffeine Cigarettes Alcohol Marijuana Prescription Over the Counter Street Drugs Other Amount/Frequency
3 Psych History: Individual Therapy: Family Therapy: Group Therapy: Psychiatric History: Diagnosis Known: History of suicidal thoughts?: History of suicidal attempts?: Psychiatric ER Visit: _ Psychiatric Hospitalization: Family Psychological or Psychiatric History: Medical History: Pediatrician s Name: Pediatrician s #: Last Dr visit: Results of exam Medical Concerns: Major Illnesses: Medical Hospitalizations: Surgeries: Medical Challenges: Sleep Problems Eating Problems Specialists: Family Medical History:
4 Current Medication: Dosage: Times Per Day: For Treatment of: Legal History: History of Abuse?: Describe child s social network/support: Describe child s present religious affiliation: Is this important to you?: What are the reason(s) for your visit?: How long has this problem persisted?: Under what conditions do your problems usually get worse?: Under what conditions are your problems usually improved?: What are your therapy goals?: _ What are your expectations?: What are your child s strengths?: Your child s weaknesses are:
5 Loses temper easily Argues with adults Irritates people Externalizes blame Easily annoyed Truant at school Hyperactive Loses things Easily distracted Interrupts others Poor grades Expelled Drug abuse Avoidant/shy Anxious/nervous Depression Fatigued Excessive worry Sleep problems Panic attacks Mood shifts Medical ailments Sibling rivalry Phobias/fears
6 Academic Problems Addictions ADHD Aggression Anxiety Avoidant Beh. Career Problem Compulsiveness Cultural Concern Depression Discrimination Dizziness Eating Disorder Elevated Mood Family Problem Fatigue Financial Hallucinations Harassment Identity Concern Internet Problem Impulsivity Intimacy Issues Interpersonal Irritability Judgment Errors Leal Concerns Loneliness Loss/Grief/Death Manic Episodes Medical Concern Memory Problems Mood Shifts Obsessive Panic Attacks Paranoia Phobias Physical Abuse Procrastination Recurring Thoughts Relationship Self Esteem Sexual Problems Sick Often Sleep Problems Speech Problems Spiritual Concern Stress/Tension Suicidal Thought Thoughts Disorganized Thoughts Racing Trembling Trouble Making Decisions Withdrawing Worrying Other (specify) Please give examples of how each of the symptoms that you checked impairs your child s ability to function (e.g., socially, emotionally, occupationally, physically, etc.). Use the back of this sheet if necessary
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:
CLIENT CLIENT INTAKE FORM Client Information Name: Birthdate: Gender: Address: Is it safe to send correspondence to this address, if needed? Yes No Phone: (Home) (Work) (Cell) Is it safe to contact/leave
COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):
Joanna C. Ioannides, LCSW *Lowry Counseling, LLC *7581 E. Academy Blvd. Ste 209 * Denver, CO 80230*Ph. (720)319-7319 Fax (303)379-4607* counseldenver@aol.com* COUNSELING ASSESSMENT REFERRAL AND BACKGROUND
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Intake Form Name: Date: *If attending couples or family therapy please complete one form for each individual attending treatment. Presenting Problems and Concerns Describe the Problem that brought you
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York 10549 jablownp@optimum.net (914) 241-1246 Personal Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Address: City: State: Zip:
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005
Sofia P. Simotas, Ph.D., PLLC 2524 Nottingham St. Houston, Texas 77005 INTAKE FORM Name: Date: Gender: Female Male Date of birth: Address: Home phone: Cell: Okay to leave a message? Yes No Email: Emergency
Child/ Adolescent Questionnaire
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Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
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
Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
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Child and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM
Email: Dr.Grevin@eastbaypsychotherapyservices.com www.therapywalnutcreek.com CHILD HISTORY FORM Date Child s name Last First Child s birth date Gender Home address(es) Parent(s) names(s): Home phone (s)
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE. Birth date: Age: Sex (circle one): Male Female. Home address: City: Zip Code:
DR. CESTNICK ADULT BACKGROUND QUESTIONNAIRE Your name: Today s date: Birth date: Age: Sex (circle one): Male Female Home address: City: Zip Code: Phone: Home # Cell # Other # Email: School (if student):
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
Assessment Intake/History Form
Assessment Intake/History Form PATIENT INFORMATION Patient Name: Date of Birth: Age: Parent/Guardian Name(s): Who has legal custody of this child? Please circle one of the following: Address: City, State,
Katarina R. Mansir, Psy.D. Licensed Psychologist PSY25417 (858) Name: Date: Presenting Concerns
Name: Date: Presenting Concerns Briefly describe what brings you to therapy. Approximately how long has this concern been bothering you? Day Week Month Several months Year Several years Most of my life
Medications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
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Demographic Information Form
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Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
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Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA Phone: (707) FAX: (707)
Humanistic Psychological Services 831 Alamo Drive, Suite 5C, 6B, 6C Vacaville, CA 95688 Phone: (707) 624-9767 FAX: (707) 471-4140 Intake Paperwork for Adult Today s Date Referred By Please take time to
CHILD AND ADOLESCENT BEHAVIORAL HEALTH HISTORY
7700 Cat Hollow Dr., Ste. 206 (512) 807-8457 Phone Round Rock, Texas 78681 (512) 501-2259 Fax www.greatoakscounselingcenter.com CHILD AND ADOLESCENT BEHAVIORAL HEALTH HISTORY Child/Teen s Name: School:
Very much. N/A No A little Pretty much. Making careless mistakes
Weiss Symptom Record The following is a list of different kind of problems. Everyone has some of these difficulties at some time. We want to know if any of these things are causing more difficulty than
Name of Child or Adolescent M/F Today s Date. Birth Date: Age: Name of Person filling out form (Parent or Adolescent): REASON FOR SEEKING TREATMENT
1 Jill Jacobson Ph.D. Washington State Psychologist License #60032612 555 Dayton Suite A-3 Edmonds, WA 98020 jacobsonadvisors@earthlink.net www.drjilljacobson.com (206) 778-3458 Child or Adolescent History
New Patient Information Form
New Patient Information Form Patient Identification Prenatal Alcohol & Drug Exposure Clinic FASD CLINIC Patient s OHIP N. Female Male Race Patient s Name Birth Date Age First Middle Last Patient s Address
APPENDIX. TKJ Forms. The following forms have been created by TKJ in conjunction with this training manual:
APPENDIX TKJ Forms The following forms have been created by TKJ in conjunction with this training manual: Form 1 : Functional Assessment Form 2 : Brief Functional Assessment Interview Form Form 3 : Behavior
Child s Information (Please print) Name Birth Date Age Home Address City State Zip Code
The following questions are asked so that we can best understand your child. Please fill out this questionnaire before the child is evaluated. Please read the questions carefully and answer them as fully