Child’s Name:

/ Child/Youth Intake Form / 4505 E. 47th St. South
Wichita, KS 67210
316.264.8317
Fax 316. 264.0347

CHILD’S INFORMATION:

NAME: ______FCS ID#: ______KAECSES #: ______

First name Middle Initial Last Name

DOB: ______AGE: ______SS NUMBER:______GENDER: Male Female

ADDRESS: ______APT. #:______

CITY:_____ STATE:______ZIP:______COUNTY:______

PHONE NUMBER: ______

Home Cell

Email Address: ______

RACE/ETHNICITY OF CHILD Caucasian/White Japanese Hispanic African American/Black Chinese

Native American Biracial Asian Hawaiian Vietnamese Other

Are there any communication barriers for the child or parent/guardian? ______

Caregiver information: Parent Relative Guardian resource parent

NAME: ____________

Last nameFirst NameMiddle Initial

ADDRESS: (if different)______PT. #:_____

CITY:_____ STATE:______ZIP:______COUNTY:______

PHONE NUMBER: ______

Home Cell Work

List household members: ______

Are there any immediate family members in the military? ______If so, have they served in combat?______

Who is legally authorized to receive information about and make decisions regarding this child’s care?

______

Name and Relationship

CASE MANAGER/PO:______AGENCY:______PHONE:______N/A

REFERRED BY: ______

Is Treatment Court Ordered?YES NO

Employment information: Full-time Student Part-time Student Employed N/A

Name of Employer: ____ Job Title: ______

LEGAL HISTORY:

Has the child been charged with a crime Yes No Is the child on probation? Yes No

If yes, please explain:______

SUBSTANCE USE HISTORY: NONE Attended alcohol/drug abuse treatment: Yes No

Alcohol Other substance use ______

SOCIAL, PLAY AND RECREATION: Describe the child’s social, play and recreational interests:

______

School Functioning:

Current School:______Elementary Middle School High School

Grade: ______Teacher’s Name: ______School Phone Number:______

Past/ Present truancy: Yes No Expulsions: Yes No Number ___Dates:______

SuspensionsYes No In school Out of school Number ______Dates______

Asked to leave a daycare/preschoolYes No Number ______Dates ______

504 Plan Special Education / IEP ______

Mental Health History:

No previous therapy

Outpatient Treatment

Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy

Provider: ______

Dates of treatment: ______

Reason for treatment: ______

INPATIENT PSYCHIATRIC HOSPITALIZATION:

Previously hospitalized: Yes No N/A Multiple Hospitalizations: Yes ______

Last psychiatric facility:______Date Admitted______Date Dismissed______

PRIMARY CARE PHYSICIAN (PCP):

NAME:______PHONE:______

ADDRESS: ______

Visit/Checkup with PCP within the past 12 months: Yes No Regular preventative health screens: Yes No

Currently prescribed medications: (Medication, dosage and prescribing physician):

______

Has the child been consistently taking these medications as prescribedYesNo

PATIENT MEDICAL/health: (Please check all that apply – past or current)

Past Current Past Current Past Current

Asthma / High Blood Pressure / Frequent ear infections
Head injury / Thyroid Problems / Dental problems
Cancer / Kidney Disease / Tuberculosis
Seizures / Significant wt. gain/loss / Gastro Intestinal Problems
Diabetes / Hepatitis / Other______

Is the child currently being seen for any of the above? Yes No If yes, please describe______

History of hospitalization due to a medical condition: Yes No If yes, please describe______

Medication Allergies ______

Nutrition: (Please check all that apply – past or current)

Past Current Past Current Past Current

Increased Appetite Binge Eating Other______

Decreased Appetite Hoarding

Is the child currently being seen for any of the above? Yes No please Describe______

Food Allergies ______

I have made myself throw-up after eating Yes No I do not eat a wide variety of healthy foods Yes No

PAIN: Past Current N/A

Chronic Pain If Yes, please describe: ______

Is the child currently being seen for any of the above? Yes No If yes, please Describe______

The child experiences a decrease in ability to function in life due to this pain Yes No

PSYCHIATRIC HISTORY:

Past CurrentPast Current Past Current

ADHD Abuse: sexual Other ______

AnxietyAbuse: physical Bipolar Disorder

DepressionEating Disorder

DEVELOPMENTAL HISTORY:

PREGNANCY: Full term Premature LateDELIVERY: Normal Delivery C-Section

Problems during pregnancy______

MILESTONES: WALKING _____ months TALKING ______months TOILET TRAINED ______months

FAMILY MEDICAL HISTORY

___ Diabetes ___ Heart Disease___ Anxiety___ Psychiatric hospitalizations

___ Depression___ Schizophrenia___ Suicide attempts___ Alcohol/drugs

___ ADHD___ Bipolar Disorder___ Antisocial behavior (difficulties – police/violence)

Visitation Arrangements:Are there any custody/visitation arrangements? Please describe, noting any court orders:

DESCRIBE YOUR FAMILY, CULTURE AND RELIGIOUS CONNECTIONS

HAVE YOUR CHILD EXPERIENCED GRIEF OR LOSS:

General FunctioninG: (Please check all that apply)

Cheerful/happy mood most of the time Extreme ups and downs in mood Conflict with authority figures

Sad or tearful most of the time Irritability/anger Stealing

Feelings of hopelessness Distinct periods of nonstop activity Physical cruelty to animals

Withdrawn behaviors Exaggerated view of abilities Physical aggression

Difficulty thinking Fast/rapid speech Verbal threats to harm others

Under active/sluggish behavior Feels rested after 3-4 hours sleep/ night Threat to kill with intent /plan

Intentional self harm Fearless/engaging in reckless activities Lying

Suicidal thoughts Fearful of places, situations or people Extreme conflict with siblings

Suicide attempts Worries about ______Running away

Sleepwalking Wetting accidents Poor social skills

Soiling Accidents Inability to complete tasks Poor self-care/poor hygiene

Nightmares Sexual inappropriate touching of others Easily distracted

Takes more than an hour to fall asleep Sexual play with toys or objects Difficulty concentrating

Night waking for longer than 30 minutes Excessive masturbation Overactive/hyperactive behavior

Hard to wake up in the morning Intentional vomiting/purging Unable to sleep in own bed

How long have you had these concerns? ______

How often do these occur? ______

What are your child’s strengths?______

FCS Counseling/Emberhope is an equal opportunity employer. Services are provided to people without regard to race, religion, color, sex, ancestry, national origin, handicap, age or political affiliation.

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