Tel 320-257-1800 Fax 320-257-1801 818 2nd Street South, Suite 180 Waite Park, MN 56387 www.granitecitycounseling.
com
DATE___________________
CHILD/ADOLESCENT CLINICAL INTAKE
(THIS FORM WILL NEED TO BE COMPLETED AND RETURNED AT THE TIME OF
YOUR FIRST APPOINTMENT.)
In order for us to be able to fully evaluate your child, please fill out the following questionnaire to
the best of your ability. We realize there may be information that you do not remember or have
access to; do the best you can. Thank you.
PATIENT IDENTIFICATION
Name___________________________________________
Birth Date__________________________ Age ______________ Sex ___________
Race_______________________________
Address_________________________________________________________________
City________________________________State______________ Zip______________
Home Phone #___________________ Parent’s work # _______________(specify mom or dad)
Cell Phone #_____________________ (specify mom or dad)
Who is the child/teen currently living with? ________________________________________
Address of other parent_____________________________________________________
City______________________________________ State__________ Zip____________
Legal Guardians:___________________________________________________________
Name of person completing this form_________________________________________
Emergency Information
In case of emergency, contact:
Name:_______________________________Relationship_______________ Phone_________
It is your responsibility to inform Granite City Counseling of changes in address, phone #,
insurance coverage.
In an effort to coordinate care, we would like to obtain/give information from previous providers
and/or your referral source. With your written authorization, we will be informing your
child’s physician (by letter) of his/her diagnosis and care here, communicating (as
necessary) with the referring agent and requesting past mental health records.
Do you wish to sign an authorization for release of information for the following?
Physician’s Name:_____________________________________________________ Yes No
Past Mental Health Agency/Counselor:____________________________________ Yes No
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REFERRAL SOURCE
Referral Source __________________________________________Phone #__________
REASONS FOR THERAPY
Primary reason for seeking therapy:__________________________________________
_______________________________________________________________________
How long have these problems been developing?________________________________
_______________________________________________________________________
Has therapy been discussed prior to the appointment? Circle: Yes No
If yes, what was the child/teen’s reaction?______________________________________
________________________________________________________________________
GOALS
What are the goals for your child’s therapy?____________________________________
_______________________________________________________________________
_______________________________________________________________________
SYMPTOM CHECKLIST
Please rate the symptoms your child/teen is currently experiencing using the following scale:
0 – never; 1 – mild; 2 – moderate; 3 – severe
Group A Group B
__Seems sad or unhappy __Physical problems like headaches,
__Suicidal comments stomachaches, dizziness, nausea,
__Self-abusive behavior loose stools, shakiness
__Has trouble falling or staying asleep __Excessive worry
__Sleeps too much __Lacks confidence in abilities
__Poor appetite __Needs lot of reassurance
__Increased appetite __Needs to be perfect
__Significant weight gain __Seems fearful and anxious
__Significant weight loss __Seems shy or timid
__Talks about feeling stupid or worthless __Easily embarrassed
__Loses interest in having fun __Sensitive to criticism
__Seems irritable __Bites fingernails
__Moody __Has nervous habit
__Has low energy __Nightmares/disturbing dreams
__Often plays alone/avoids others __Has fears and phobias
__Cries easily/frequently __School refusal
__Poor concentration __Difficulty separating from parent
__Grades have dropped __Excessive checking, counting, washing,
__Memory impaired cleaning, organizing, evening things out
__Loneliness __Doesn’t sleep in own bed
__Low self-esteem __Problems with sleep
__Evidence of frequent anger __Muscle tension
__Decreased need for sleep __Restless/keyed up
__More talkative than usual __Pounding/racing heart
__Restlessness __Sweating
__Moving slowly __Trembling
__Feeling agitated __Trouble breathing
__Feeling hopeless __Chills/hot flushes
__Low motivation __Numbness
__Feeling of choking
__Chest pain
__Nausea/abdominal distress
__Feeling dizzy
__Fear of losing control
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Group C
__Always on the go
__Can’t sit still
__Doesn’t seem to listen
__Often fails to finish things
__Has difficulty keeping attention in tasks or play activities
__Often loses things necessary for tasks or activities (school assignments, pencils, books)
__Often fidgets with hands/feet or squirms in seat
__Easily distracted
__Has a hard time playing quietly
__Talks excessively
__Often interrupts or “butts in” to others’ games
__Seems disorganized, loses things needed for school
__Takes risks without considering the danger involved (i.e. running into the street
without looking
__Blurts out answers to questions before they have been completed
__Often has difficulty awaiting turn
__Often leaves seat in situations in which remaining seated is expected
__Is often forgetful in daily activities
__Makes careless mistakes on schoolwork or other activities/fails to pay attention to
details
__Often does not follow through on instructions and fails to finish school work, chores
or duties
__Avoids activities that require sustained mental effort (such as homework)
Group D Group G
__Refuses to follow rules or adults’ requests __Excessive appetite
__Loses temper __Underweight
__Argues with parents or teachers __Exercises excessively
__Blames others for mistakes/misbehavior __Use of self-induced vomiting
__Swears __Misuse of laxatives
__Deliberately does things to annoy other people __Intense fear of gaining weight even
__Is angry or resentful though underweight
__Carries a grudge; seems to have a “chip on shoulder” __Evaluates self based on body shape
__Touchy; easily annoyed by others and weight
__Spiteful or vindictive
Group H
Group E __Abnormal posture
__Wets: __daytime __nighttime __Clumsiness
__Soils: __daytime __nighttime __Muscle weakness
Group F
__Alcohol/drug use
__Smoking
__Caffeine Use
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Group I Group J
__Steals (circle in or out of home setting) __Difficulty making and keeping
__Runs away overnight friends
__Lies __Difficulty with teachers
__Skips school __Poor choice of friends
__Is cruel to animals
__Destroys property Group K
__Gets into fights __Inappropriate sexual talk
__Has been physically cruel to other people __Sexual abuse of others
__Doesn’t seem sorry for hurting others __Overly friendly with strangers
__Sets fires/dangerous play with fire
__Has broken into someone else’s house or car
__Legal problems
Group L
__Recurrent and upsetting thoughts of a past traumatic event_________________________
__Recurrent distressing dreams of a past upsetting event
__A sense of reliving a past upsetting event
__A sense of panic or fear to events that resemble an upsetting past event
__Spending effort avoiding thoughts or feelings associated with a past trauma
__Inability to recall an important aspect of a past upsetting event
__Persistent avoidance of activities or situations that cause him/her to remember a past upsetting
event
__Marked decreased interest in important activities
__Feeling detached or distant from others
__Feeling numb or restricted in your feelings
__Feeling that his/her future is shortened
__Quick startle response
__Feeling like he/she is always watching for bad things to happen
Group M
__Impairment in the use of nonverbal behaviors such as eye-to-eye gaze, facial expression, body
postures and gestures to regulate social interactions
__Failure to develop peer relationships
__Lack of showing, bringing, or pointing out objects of interest to other people
__Lack of social or emotional reciprocity
__Inflexible adherence to specific, nonfunctional routines or rituals
__Hand or finger flapping or twisting
__Difficulty identifying when someone is teasing
__Fails to predict probable consequences in social events
__Difficulty making believe or pretending
__Talks about a single subject excessively
__Shows an intense, obsessive interest in certain intellectual subjects
__Unaware of or insensitive to the needs or feelings of others
__Demonstrates eccentric forms of behavior
__Preoccupation with specific subjects or parts of objects
__Expresses feelings of empathy inappropriately
__Seems unaware of social conventions or codes of conduct
__Becomes frustrated quickly when unsure of what is required
__Displays clumsy and uncoordinated gross motor movements
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FUNCTIONAL IMPAIRMENT
The reported symptoms have created difficulty in the following areas:
SCHOOL:
__not difficult __somewhat difficult __very difficult __extremely difficult
GETTING ALONG WITH OTHERS:
__not difficult __somewhat difficult __very difficult __extremely difficult
TAKING CARE OF THINGS AT HOME:
__not difficult __somewhat difficult __very difficult __extremely difficult
FAMILY IDENTIFICATION AND HISTORY
Please name each person (including parents, stepparents, adoptive parents, or full, half or step
siblings) CURRENTLY living in the same household as this child/teen:
_____________________________________ _______ __________________________
Person # 1 Age Relationship to client
______________________________________ _______ __________________________
Person # 2 Age Relationship to client
______________________________________ _______ __________________________
Person # 3 Age Relationship to client
______________________________________ _______ __________________________
Person # 4 Age Relationship to client
______________________________________ _______ __________________________
Person # 5 Age Relationship to client
Is there another household in which the child lives? _____Yes _____No
Please name each person living in the second household as the child:
______________________________________ _______ ___________________________
Person #1 Age Relationship to client
______________________________________ _______ ___________________________
Person #2 Age Relationship to client
______________________________________ _______ ___________________________
Person #3 Age Relationship to client
______________________________________ _______ ___________________________
Person #4 Age Relationship to client
______________________________________ _______ __________________________
Person # 5 Age Relationship to client
Has this child experienced the loss by death of any individual or pet significant in his/her life? If
yes, please describe who, when and how: ____________________________________________
_____________________________________________________________________________
_______________________________________________________________________
Has this child experienced the divorce or breakup of the parents’ relationship? If yes, please
describe the child’s reaction to the breakup.___________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Is this child adopted? _________ If so, at what age? __________
Describe any difficulties, if any, that are related to being adopted.___________________
________________________________________________________________________
Describe any relationship difficulties this child/teen may have with any member of the
household______________________________________________________________________
______________________________________________________________________________
Biological Mother’s History: Age_______ Outside work_______________________
School: Highest grade completed___________________ Marriages_________________
Has mother, parents, or siblings experienced any of the following problems?
Alcohol or drug abuse? Y N DK If yes, whom? _____________________
Significant depression? Y N DK If yes, whom?______________________
Suicidal attempts? Y N DK If yes, whom?______________________
Significant anxiety? Y N DK If yes, whom?______________________
Mental illness? Y N DK If yes, whom?______________________
Hospitalization for
emotional problems? Y N DK If yes, whom?______________________
Chronic physical illness? Y N DK If yes, whom?______________________
Anger problems? Y N DK If yes, whom?______________________
Learning disability/
difficulty? Y N DK If yes, whom?______________________
Behavior problems? Y N DK If yes, whom? _____________________
Childhood atmosphere growing up (family position, abuse, illnesses, etc.)_____________
Has mother ever experienced (circle if yes):
Sexual abuse Physical abuse Emotional abuse/Harassment
Has mother ever sought mental health treatment? Yes_____ No_____ If yes, for what purpose?
______________________________________________________________________________
Biological Father’s History: Age________ Outside work________________________
School: Highest grade completed____________________ Marriages_______________
Has father, parents, or siblings experienced any of the following problems?
Alcohol or drug abuse? Y N DK If yes, whom? _____________________
Significant depression? Y N DK If yes, whom?______________________
Suicidal attempts? Y N DK If yes, whom?______________________
Significant anxiety? Y N DK If yes, whom?______________________
Mental illness? Y N DK If yes, whom?______________________
Hospitalization for
emotional problems? Y N DK If yes, whom?______________________
Chronic physical illness? Y N DK If yes, whom?______________________
Anger problems? Y N DK If yes, whom?______________________
Learning disability/difficulty?Y N DK If yes, whom?______________________
Behavior problems? Y N DK If yes, whom? _____________________
Childhood atmosphere growing up (family position, abuse, illnesses, etc.)_____________
________________________________________________________________________
Has father ever experienced (circle if yes):
Sexual abuse Physical abuse Emotional abuse/Harassment
Has father ever sought mental health treatment? Yes_____ No_____ If yes, for what purpose?
______________________________________________________________________________
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(If Applicable)
Step or Adoptive Mother’s History: Age_____ Outside work ___________________
School: Highest grade completed_____________ Marriages______________________
Has step or adoptive parent experienced any of the following problems?
Alcohol or drug abuse? Y N DK If yes, whom? _____________________
Significant depression? Y N DK If yes, whom?______________________
Suicidal attempts? Y N DK If yes, whom?______________________
Significant anxiety? Y N DK If yes, whom?______________________
Mental illness? Y N DK If yes, whom?______________________
Hospitalization for
emotional problems? Y N DK If yes, whom?______________________
Chronic physical illness? Y N DK If yes, whom?______________________
Anger problems? Y N DK If yes, whom?______________________
Learning disability/
difficulty? Y N DK If yes, whom?______________________
Behavior problems? Y N DK If yes, whom? _____________________
Childhood atmosphere growing up (family position, abuse, illnesses, etc.)_____________
________________________________________________________________________
Has step or adoptive parent ever experienced (circle if yes):
Sexual abuse Physical abuse Emotional abuse/Harassment
Has step or adoptive parent ever sought mental health treatment? Yes_____ No_____ If yes, for
what purpose?______________________________________________________________
(If Applicable)
Step or Adoptive Father’s History: Age_____ Outside work ___________________
School: Highest grade completed_____________ Marriages______________________
Has step or adoptive parent experienced any of the following problems?
Alcohol or drug abuse? Y N DK If yes, whom? _____________________
Significant depression? Y N DK If yes, whom?______________________
Suicidal attempts? Y N DK If yes, whom?______________________
Significant anxiety? Y N DK If yes, whom?______________________
Mental illness? Y N DK If yes, whom?______________________
Hospitalization for
emotional problems? Y N DK If yes, whom?______________________
Chronic physical illness? Y N DK If yes, whom?______________________
Anger problems? Y N DK If yes, whom?______________________
Learning disability/difficulty?Y N DK If yes, whom?______________________
Behavior problems? Y N DK If yes, whom? _____________________
Childhood atmosphere growing up (family position, abuse, illnesses, etc.)_____________
________________________________________________________________________
Has step or adoptive parent ever experienced (circle if yes):
Sexual abuse Physical abuse Emotional abuse/Harassment
Has step or adoptive parent ever sought mental health treatment? Yes_____ No_____ If yes, for
what purpose?______________________________________________________________
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DEVELOPMENTAL HISTORY
Prenatal events:
Check: Planned pregnancy______ Unplanned pregnancy____
Pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking,
alcohol/drug use, etc.)______________________________________________________
________________________________________________________________________
Birth and Postnatal period:
Birth weight________ Length__________ Labor duration__________________
Delivery: Vaginal_________ C-section________ Full-term_______ Premature________
Any other complications:___________________________________________________
Mother’s health after delivery: Post delivery blues?______ If yes, how long?______
Primary caretaker for child: First year______________________________________
Thereafter_______________________________________________________________
Feeding history: breast_____ bottle______ age weaned______________
Food allergies:____________________________________________________________
Eating problems:__________________________________________________________
Separations from mother and father: Why?__________________________________
Age_________ How long?______________________
Motor development:
(parentheses listed are approximate normal limits)
rolls over (3-5 months) ____yes ____no sit without support (5-7 months) ____yes ____no
crawls (5-8 months) ____yes ____no walks well (11-16 months) ____yes ____no
runs well (2 years) ____yes ____no rides tricycle (3 years) ____yes ____no
throws ball overhand (4 years) ____yes ____no
fine and gross motor coordination ____yes ____no
List any occupational therapy services:________________________________________
_________________________________________________________________________
Language development:
(parentheses listed are approximate normal limits)
several words besides dada, mama (1 year) ____yes ____no
names several objects – ball, cup (15 months) ____yes ____no
3 words together – subject, verb, object (24 months) ____yes ____no
vocabulary______________________ articulation____________________
comprehension__________________
List any current problems:_______________________________________________________
_____________________________________________________________________________
List any speech or language services:_______________________________________________
_____________________________________________________________________________
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Early social development:
(parentheses listed are approximate normal limits)
smile (2 months) ____yes ____no shy with strangers (6-10 months) ____yes ____no
separates from mother easily (2-3 years) ____yes ____no
cooperative play with others (4 years) ____yes ____no
early peer interactions_____________________________________________________
special interests__________________________________________________________
relationships to family members_____________________________________________
Toilet training:
age reached bowel control: day_________ night_________
age reached bladder control: day_________ night_________
current function__________________________________________________________
Early behavioral/discipline problems (prior to age 5 years):
disobeys property destruction stealing
rule breaking fire setting harming animals
physical harm to others harm to self lying
Methods of discipline
Please describe:___________________________________________________________
How frequently used or needed?_______________________________________________
Early emotional development (prior to age 5 years):
Check: irritable happy cries excessively
easily calmed content defiant
nervous habits___________________________________________________________
fears/phobias____________________________________________________________
special objects (blankets, dolls, etc.)__________________________________________
ability to express feelings___________________________________________________
Sexual development
Has this child sought any sexual information from parents? Yes_______ No________
If yes, please describe nature of questions and manner they were handled:_____________
______________________________________________________________________
Has this child ever behaved or spoken in a way that was not sexually appropriate for a person
his/her age? Yes_______ No_______ Please describe:
Nature of comment or behavior:____________________________________________
Age of child at the time:_________
Who noticed or heard?___________________________________________________
Any current concerns about your child’s sexual behavior? Circle: Yes No
If yes, please describe:___________________________________________________
Any concerns related to the use of Internet pornography or other forms of pornography?
Y N DK If yes, please describe_____________________________________________
History of Abuse:
Physical abuse: by whom?______________________ what ages?_______________
Sexual abuse: by whom?______________________ what ages?_______________
Verbal/Emotional abuse: by whom?_______________ what ages?________________
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SUBSTANCE USE HISTORY:
Did you use chemical substances while pregnant with your child? _____Yes _____No
Does your child/teen consume alcohol? _____Yes _____No
Does your child/teen consume caffeinated beverages _____Yes _____No
Does your child/teen use tobacco? _____Yes _____No
Does your child/teen use street drugs? _____Yes _____No
Has your child/teen ever misused prescription medications (eg pain pills)? _____Yes _____No
Has alcohol or drugs caused any problem for your child/teen in the past or present?
_____Yes _____No
Has your child/teen ever been in chemical dependency treatment? _____Yes _____No
Is there a history of any type of chemical use issues in the child’s family of origin
_____Yes _____No
SOCIO-ECONOMIC HISTORY:
School History:
name of school___________________________________________________ grade_____
number of schools attended______ grades repeated____________
average grades_________ homework problems__________________________________
specific learning disabilities___________________________________________________
special services at school______________________________________________________
strengths/activities___________________________________________________________
motivation_________________________________________________________________
what have teachers said about the child/teen_______________________________________
Is your child employed? _____Yes _____No
Hobbies and leisure activities:__________________________________________________
__________________________________________________________________________
Extra-curricular activities/current interests________________________________________
__________________________________________________________________________
Social Support System:
____supportive network
____no friends
____a few friends
____substance use based friends
Legal:
Has your child/teen ever been charged with a legal violation? ____Yes ____No ____Don’t Know
If yes please describe__________________________________________________________
___________________________________________________________________________
Is your child/teen on probation? ____Yes ____No
Religion:
Religious preference___________________________________________________________
Spiritual beliefs are an important part of child’s life ____Yes ____No
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EMOTIONAL/PSYCHIATRIC HISTORY
Please indicate all services that have been or currently are being used to address current problems.
____Social Services/Social Worker ____Counselor/Therapist
____Family Therapist ____Spiritual Advisor ____Mentor
Prior inpatient treatment__________________________________________Mo/Yr__________
Provider Name:_________________________________________________________________
Prior outpatient treatment_________________________________________Mo/Yr___________
Please describe your child’s experience with the above services. Was he/she helped? How did
he/she feel about the above services and/or prior therapy?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
MEDICAL HISTORY
Current medical problems:__________________________________________________
Current medications:_______________________________________________________
Past medical problems/medications:___________________________________________
________________________________________________________________________
Name of physician_________________________________________________________
Any history of head trauma? ________________________________________________
Ever any seizures or seizure like activity?______________________________________
Any periods of spaciness or confusion?________________________________________
Prior hospitalizations (place, cause, date, outcome):______________________________
_______________________________________________________________________
Prior abnormal lab tests, X-rays, EEG, etc.:_____________________________________
Allergies/drug intolerances? (Describe):_______________________________________
________________________________________________________________________
Present Height_______________ Present Weight____________
STRENGTHS
Overall strengths of child/teen – as viewed by parents___________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Overall strengths – as viewed by the child/teen_________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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STRESSORS
Have any of the following caused stress for this child/teen? (Please check below. For any
checked item, please write the year of occurrence behind the event, and include any specific
details in the space below.)
____Moved ____Changed school
____School harassment, bullying, or violence ____Serious illness or injury in family
____Change in family financial status ____Family financial problems
____Job change in family ____Parent starting work outside home
____Divorce or separation ____Sibling leaving home
____Foster care placement ____Family legal problems
____Other out of home placement(s) ____Traumatic event(s)
____Parental conflict/family violence ____Housing inadequate
____Educational deficits ____Support group deficient
____Other Stressors (please list) ___________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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