CHILD INTAKE FORM

GENERAL INFORMATION
Please provide the following information and answer the questions. Information you provide here is protected as confidential
information. Please fill out this form and bring it to your first session.

Child’s Name: Today’s Date:

Child’s age: Date of Birth (DOB):
Address:

Parent’s Name: Parent’s Name:

Home phone: May I leave a message? Yes No

Cell phone: May I leave a message? Yes No
Work phone: May I leave a message? Yes No
Email: May I email you? Yes No
(For appointment scheduling purposes only, as email not considered a confidential medium of communication).

Who referred your child to Renovation Counseling? Please provide agency/professional’s name & tel #:

May I contact the agency/person to thank them for referring you? Yes No Please initial:

What is the main reason(s) you’re seeking help for your child? (Include how long he/she’s had these symptoms or problems):

What are your hopes regarding your child’s therapy?

HEALTH & MENTAL HEALTH INFORMATION

Does your child currently have any medical problems?

Has your child ever been treated for any of the following? If so please circle and describe:
Head injury or loss of consciousness, frequent ear infections, tubes placed, hearing or vision problems, headaches, meningitis, seizures,
asthma, elevated lead levels, slow/fast growth, allergies, cancer, surgeries, any other conditions:

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 Has your child previously seen a therapist or psychiatrist? If so, what year? Who did he/she see and for what reason? About
how many meetings did your child have? Was the experience helpful or not? How so?

Has your child ever been hospitalized for medical or mental illness? If so, list when, where, & reason:

Please list your child’s current prescription medications with dosage (psychiatric and general health):

Please list any previous psychiatric medications (with dosage and dates):

Do you suspect or know your child drinks alcohol or uses recreational drugs? If so, what kind & how often?

Do you or anyone close to your child consider his/her use to be a problem? Yes No

Who is your child’s primary care physician?

Who is your child’s psychiatrist (if applicable)?
When was your child’s last complete physical exam (mo/year)?

How many times a week does your child exercise? What type & how many minutes?

What types of food does he/she often eat?

YOUR CHILD’S FAMILY

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 BIOLOGICAL MOTHER BIOLOGICAL FATHER

Current age, or if deceased, date,

age, & cause of death

Country of Origin

Occupation

Religious/Spiritual Affiliation
(if any)

Highest grade completed

Any history of the following Learning Problems Learning Problems

(please circle) Speech Problems Speech Problems
Medical Problems Medical Problems
Emotional Problems Emotional Problems
Alcohol or Substance Abuse Alcohol or Substance Abuse

Describe each parent’s

relationship with the child
Give some examples of things that you
do together & feelings you have

Parents are (choose one): Married Separated Divorced Living Together

If separated or divorced, how old was your child when the separation occurred?
Child lives with (choose one): Both parents Mother Father Other
Who has legal custody?
Please describe the current visitation schedule (if any) and type of communication with child’s other parent:

Siblings
Please list your child’s brothers and sisters in the order of birth (including adopted or step siblings).
First name Biological, Current School Male/ Lives Any medical, social or
Adopted or Age grade? Female with you? academic problems (please list
Step (Yes/No) for each)?

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 FAMILY MENTAL HEALTH HISTORY
In the section below identify if any members of your family and extended family has a history of any of the following. If yes, please
indicate the family member’s relationship to you in the space provided.

Please circle List Family Member(s)

Anxiety (general) Yes No
Obsessive Compulsive Behavior Yes No
Depression Yes No
Suicide Attempts Yes No
Bipolar/Manic Depressive Yes No
Alcoholism Yes No
Substance Abuse Yes No
Domestic Violence Yes No
Eating Disorders Yes No
Obesity Yes No
Schizophrenia Yes No
Counseling or Psychotherapy Yes No
Psychiatric Hospitalizations Yes No

YOUR CHILD’S DEVELOPMENTAL HISTORY

Pregnancy and Birth

Where there any complications during pregnancy (high blood pressure, diabetes, hospitalization): If so, please describe:

Medications used during pregnancy? Please list:

Smoking? Yes No How much?
Alcohol intake? Yes No How much?
Drug intake? Yes No How much?
Length of pregnancy? Weeks Age of mother at birth: Birth weight:
Were there any complications during delivery? If so, please describe:

Length of stay in the hospital? Mother: (days) Child: (days)

Developmental Milestones and Early Development

At what age did your child do the following (indicate approximate month or year of age for each):
Turn over Crawl Stand Alone Walk Alone
First Words First Phrases
Toilet trained? Yes No If yes, days? Nights?

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 Has your child wet or soiled himself after being trained? Yes No If yes, until what age?
Enjoyed cuddling? Yes No Fussy, Irritable? Yes No More active than other babies? Yes No
If your child has siblings, was development different in any way? Explain:

YOUR CHILD’S SCHOOL, HOME, SOCIAL & PERSONAL FUNCTIONING

School/Academics
Your child’s current grade? Has he/she ever repeated a grade? Yes No If so, which?
School name: Public or Private (circle one)?
Street Address:
School District/County? Phone: ( )

What preschool experience did your child have?

Where any problems detected in your child’s kindergarten screening? Yes No If so, please explain:

Is your child in a regular classroom? Yes No Does your child have an IEP ? Yes No
Has your child ever received tutoring? Yes No If so, please explain:
What are your child’s typical grades?
What are your child’s strongest and weakest points academically?

Are you satisfied with your child’s educational program? Yes No Please explain:

Home/Family Life
What are 5 things that you enjoy most about your child?

What are some activities you engage in as a family?

Does your child participate in any religious or faith based group?
Does your child listen and obey instructions 75% of the time? Yes No
What are your discipline techniques?

What are your strengths personally and as a parent?

What are some of your areas of needed growth?
What are your child’s strengths (things he/she is good at)?
What are your child’s areas of needed growth?
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 Social and Community Engagement
What are your child’s favorite activities or hobbies?
In what extracurricular/community activities is he/she involved?
How does your child get along with other children?
Who are some of your child’s closest friends (first name)

Your Child’s Symptoms or Problems

How much are each of the following areas currently a problem for your child?
Not at all A little Somewhat Considerabl Terribly
y
1 2 3 4 5

Anxiety 1 2 3 4 5

Physical Problems 1 2 3 4 5
Sleep Problems 1 2 3 4 5

Depression 1 2 3 4 5

Alcohol or Substance Abuse 1 2 3 4 5

Parent-Child Conflicts 1 2 3 4 5

Sibling Conflicts 1 2 3 4 5

Social Relationships 1 2 3 4 5

School Problems 1 2 3 4 5
Sexual Problems 1 2 3 4 5

Spiritual/religious 1 2 3 4 5

Legal problems 1 2 3 4 5

Eating Disorder 1 2 3 4 5
Abuse (physical, emotional, sexual) 1 2 3 4 5

Has your child experienced any stressors (recent or during the past year) that may be contributing to his/her
difficulties? Yes No
(e.g., illness, deaths, operations, accidents, separations, divorce of parents, parent changes job, child’s changes
school, family moved, family financial problems, remarriage, sexual trauma, other losses)? Yes No
If yes, please describe:

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 Please provide any additional information which you would like me to know or which you feel would be helpful
to better understand your child:

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 Therapy Agreement and Informed Consent
Please initial where indicated.

I have read and have had explained to me the following materials pertaining to therapy. My therapist has offered
me the following or I viewed it online:

_______ Privacy Notice (HIPAA)

I believe I understand the basic goals, ideas, and methods of this therapy. I have no important questions or concerns
that the therapist has not discussed with me. I understand that reaching the agreed upon therapy goal is not
guaranteed. I further understand that the initial symptoms or problems that were presented to the therapist may
initially become more intense.

With enough knowledge, and without being forced, I enter into therapy with this therapist. I will keep my therapist
fully informed about any changes in my feelings, thoughts, and behaviors. I expect us to work together on any
difficulties that occur and to work through them in my long-term interest. Our goals may have changed in nature,
order of importance, or definition.

Cancellation Policy

I understand I am welcome to come to any part of my scheduled session, even if I have to be late. If I am running
late, I will call my therapist to let him/her know. If I need to cancel or reschedule an appointment, I will give my
therapist at least 24 hour’s notice.

_______ I understand failure to attend a session without giving notice or with less than a 24-hour notice will
result in a fee equal to the full amount for the session. I understand that exceptions for unforeseen or
unavoidable situations are at the discretion of the therapist.

Payment Policy

Renovation Counseling is a self-pay counseling center, which allows clients to be seen without the involvement of
an insurance company. By paying without insurance, you protect your privacy, avoid being given an insurance-
mandated diagnosis in order to receive counseling services, and are more in control of the services you receive.

_______ I understand I may be able to receive reimbursement through my insurance provider’s out-of-network
benefits, flexible spending account (FSA), or health savings account (HSA). If I choose to do so, Renovation
Counseling can provide me with an itemized receipt of services. I understand that if I wish to use any of these
health benefits, it is my responsibility to verify coverage and submit any invoices for reimbursement. I understand
that, even if I use out-of-network, FSA, or HSA benefits, I am responsible to pay for my session in full at the
time of service, or I may prepay for sessions.

Fees

 $75 per 50-minute session before 4 pm

 $85 per 50-minute session 4 pm or later
 $110 per 80-minute session before 4 pm
 $125 per 80-minute session 4 pm or later

_______ I understand that Renovation Counseling may increase the cost per session, but that I will be notified at
least 30 days in advance of any rate increase.
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Cell phone/Email/Fax Communication

If I choose to use email or a cell phone for communication, I understand it may compromise the confidentiality of
my information in ways my therapist cannot control. I also understand my therapist may share a printer with other
therapists and that those therapists will work together to ensure my privacy to the best of their ability.

_______ I understand the security of client information is not guaranteed when information is left on a voicemail,
texted or emailed.

Case Consultation

_______ I give permission to this therapist to present my case in consultation with other professionals or
consultants and Renovation Counseling therapists, who are bound by the legal framework of privacy and
confidentiality, for professional development and guidance purposes. I understand that this agreement will become
part of my record of therapy.

Supervision

_______ I understand that my therapist is in the process of licensure and, as such, is required to receive supervision
for his/her work. I grant permission for my therapist to discuss my sessions with his/her supervisor as a condition of
my treatment.

Emergency Procedure

In the event of a life-threatening emergency, I should call 911. If I have another crisis that cannot wait I am aware I
can call the Crisis Connection at 612-379-6363. If I have a crisis plan with my therapist, I will follow that first.

Inactive Records

Your complete record will be retained for seven years after you have completed treatment. At the end of seven
years, the record will be entirely destroyed, leaving only the name of the client and date of record destruction. The
time period begins from the date of the last visit (or for minors from the date they reach 18). Should there be any
further direct client contacts the counting period will begin again at the date of new service.

Confidentiality Statement

Under the rules governing Marriage and Family Therapists in the state of Minnesota, a therapist, and employees
and professional associates of the therapist, must not disclose any private information that the therapist, employee,
or associate may have acquired in rendering services except as follows.

 When the Board of Marriage and Family Therapy is reviewing a therapist. The Board shall be allowed
access to records of a client treated by a therapist under review if the client signs a written consent
permitting access. If no consent form has been signed, the hospital, clinic, or licensee shall first delete data
in the record that identifies the client before providing it to the board.

 When disclosure is required by state law like prenatal exposure to drugs and alcohol, reports of child abuse
and neglect and vulnerable adults abuse and neglect.

 When failure to disclose the information presents a clear and present danger to the health or safety of an
individual.

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  When the person, employee, or associate is a defendant in a civil, criminal, or disciplinary action arising
from the therapy.

 When the patient is a defendant in a criminal proceeding and the use of the privilege would violate the
defendant's right to a compulsory process or the right to present testimony and witnesses in that person's
behalf.

 When a patient agrees to a waiver of the privilege accorded by this section, and in circumstances where
more than one person in a family is receiving therapy, each such family member agrees to the waiver.
Absent a waiver from each family member, a marital and family therapist cannot disclose information
received by a family member.

All other private information must be disclosed only with the informed consent of the client.

Minnesota Mental Health Bill of Rights

 Expect that a therapist has met the minimal qualifications of training and experience required by state law.

 Examine public records maintained by the Board of Marriage and Family Therapy, which contain the
credentials of the therapist.

 You may file a complaint with the Office of Mental Health Practice, 2829 University Avenue SE, Suite
340, Minneapolis, MN 55414-3239. Their phone numbers are (612) 617-2105; TTY: (800) 627-3529; and
fax: (612) 617-2103.

 You, the client, are billed directly for services, or your insurance coverage may be billed with your
permission.

 You have a right to reasonable notice of changes in services or charges.

 You have the right to receive a summary, in plain language, of the theoretical approach used by us in
working with clients.

 You have the right to complete and current information concerning our assessment and recommended
course of treatment, including the expected duration of treatment.

 You have the right to expect courteous treatment and to be free from verbal, physical, or sexual abuse by
the practitioner working with you;

 Your records and transactions with us are confidential, unless release of these records is authorized in
writing by the client, or otherwise provided by law.

 You have the right to be allowed access to records and written information from records in accordance with
Minnesota statutes.

 You should know that other services may be available in the community. To find out about such services,
you may call First Call for Help at 651-291-0211.

 You have the right to choose freely among available practitioners, and to change practitioners after services
have begun, within the limits of health insurance, medical assistance, or other health programs.
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  You have a right to coordinated transfer when there is a change in the provider of services.

 You may refuse services or treatment, unless otherwise provided by law.

 You may assert these and other rights without retaliation.

My signature on this Therapy Agreement and Informed Consent indicates that I:

 Have reviewed, understand, and consent to the policies and information above, and
 Consent for my child to participate in therapy at Renovation Counseling

Parent Signature: ________________________________________________ Date: ________________

Parent Signature: ________________________________________________ Date: ________________

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