Resilient Counseling, Wellness, & Psychological
Services, LLC
5950 Crooked Creek Rd., Ste. 290. Peachtree Corners, GA 30092
(470) 444-0005
Adolescent Intake Form
Date: ______
Identifying/Contact Information:
Child
Name: ______Birthdate: ______Age: ______Sex: M F
Address at which to send correspondence (if different than child): ______
StreetCityStateZip
Child currently living with Dad Mom Both Parents Other______
Parents:
Father’sName: ______Birthdate: ______Age: ______
Address at which to send correspondence (if different than child): ______
Street City StateZip
Home Phone:______Permission to contact child at this number Yes No
Cell Phone: ______Permission to contact child at this number Yes No
Work Phone: ______Permission to contact child at this number Yes No
Email Address: ______
Permission to contact you at email address above Yes No
Mother’s Name: ______Birthdate: ______Age: ______
Address at which to send correspondence (if different than child): ______
Street City State Zip
Home Phone:______Permission to contact child at this number Yes No
Cell Phone:______Permission to contact child at this number Yes No
Work Phone: ______Permission to contact child at this number Yes No
Email Address: ______
Permission to contact you at email address above Yes No
Parent’s marital status: Married______Divorced ______Separated______Never married______Remarried ______Other______
______Parent’s Signature Date
I was referred by: ______May we thank them? Yes No N/A
Current Concerns
Please check all areas of concern.
_____ Abused as a child/adolescent_____ Problems with parents
_____ Anger/temper_____ Resentment/Bitterness
_____ Aggression_____ Spiritual Concerns
_____ Loneliness _____ Sexual Concerns
_____ Depression_____ Stress/Anxiety/Worry
_____ Mood Swings_____ Thoughts of suicide
_____ Difficulty in communication _____ Trouble making decisions
_____ Eating difficulties_____ Unhappy most of the time
_____ Education_____ Use of alcohol/drugs by child
_____ Family problems_____ Use of alcohol/drugs by family member
_____ Fearfulness_____ Sexual identity/orientation
_____ Grief/loss_____ Self-harming behavior
_____ Personality conflicts_____ Other addiction
_____ Problems in relationships _____ Trauma/Flashbacks
_____ Feeling hopeless_____ Spells of terror or panic
_____ Concentration/Focus difficulties _____ Pornography
_____ Other:______
What has led you to seek counseling for your child at this time? ______
Education:
Current grade level:______
Does your child have any learning or developmental struggles? Yes No Please specify: ______
Medical Information:
Medication/Supplement / Dosage / Frequency / Prescribing Dr. / Start DateList any medications (including over-the-counter medicines) child currently takes:
List any allergies or adverse reactions to any medication: ______
______
Describe any past physical problems your child has had:______
Is child currently receiving medical treatment? Yes No
Has child been hospitalized in the last year? Yes No
If so, please explain: ______
How many hours does your child sleep per night? ______Does he/she snore?Yes No
Does he/she have difficulty with getting to sleep, staying asleep, interrupted sleep or waking up too early?
Yes No If yes, please describe:______
Substance Use History:
First Use / Last UseCaffeine
Alcohol
Marijuana
Pain Medication
Cocaine
Heroin
Nicotine
Morphine
Pornography
Gambling
Meth
Other
Is there a history of alcohol and substance abuse in your family? Yes No
Nutrition
Has child’s eating habits changed recently? Yes No
Does child ever self-induce vomiting? Yes No
Does child ever binge eat or do you feel his/her eating is out of control? Yes No
Does child use laxatives, water pills, or diet medications? Yes No
How often does your child exercise Daily A Few Times per Week Irregularly Never
Overall physical condition: Very Good Good Average Poor
Legal History(Please check all that apply)
Past Charges Charges presently Arrests Probation Other ______
Family Background:
Is there a history of mental health issues/addiction in parents or grandparents? Yes No
What significant events (divorce, deaths, sickness, traumas, etc.) has child experienced? ______
Spiritual Background:
How significant is your religion/spirituality to child’s everyday life?______
Religious Affiliation: ______Active Inactive
Counseling History:
Hasyour child ever had counseling before: Yes No When? ______
Hasyour child ever attempted suicide or contemplated suicide? Yes No
Does or has your child participated in cutting? Yes No
Has your child ever been hospitalized for a psychiatric or emotional health reason? Yes No
Has your child ever been in a drug, alcohol or other treatment program? Yes No
PLEASE HAVE CHILD COMPLETE THE FOLLOWING:
- The most important thing to me is...
- I worry about...
- What I do best is...
- Sometimes I feel guilty about...
- What makes me angry is...
- My biggest mistake was...
- My school...
- What makes me nervous is...
- My personality would be better if...
- I often feel that mother...
- My temper...
- My life...
- Prayer is...
- My biggest disappointment...
- I would be better liked if...
- I often feel that father...
- God, to me, is...
- Girls are...
- What hurts me most is...
- My biggest problem is...
- Boys are...
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Adolescent Intake Form