Get the free ChildAdolescent Intake History Form Part II

Lorrie G. Beavers, PhD 679 Emory Valley Rd. Suite B Oak Ridge, TN 37830 Child/Adolescent Intake History Form: Part II Child/Adolescents name: Date: Presenting Problem (include precipitating factors:)

How to fill out childadolescent intake history form

1. To fill out a child/adolescent intake history form, start by gathering all relevant information about the child or adolescent, including their personal details, medical history, and any previous therapy or counseling they may have received.
2. Begin by providing the child's full name, date of birth, and contact information. Include the names and contact information of their parents or legal guardians as well.
3. Next, fill out the medical history section of the form. This should include any known allergies, chronic illnesses, medications the child is currently taking, and any previous surgeries or hospitalizations. It may also ask about any psychiatric or psychological diagnoses the child has received in the past.
4. The form may also have a section to provide information about the child's educational background. Include their current school, grade level, any learning disabilities or special education services they may require, and their academic strengths and weaknesses.
5. There may also be a section to note any behavioral or emotional concerns. If the child has exhibited any challenging behaviors or has previously been diagnosed with any mental health disorders, provide as much detail as possible.
6. The form may ask about the family history, including any known mental health disorders or substance abuse issues among close family members. It may also inquire about the child's living situation and any recent significant life events or changes.
7. Finally, there may be a section to include any additional information or concerns. This is an opportunity to provide any relevant details that have not been covered in the previous sections.

Who needs a child/adolescent intake history form?

1. Mental health professionals and therapists often require a child/adolescent intake history form to gather comprehensive information about their new clients. This form helps them gain a better understanding of the child's background, medical history, behaviors, and any other factors that may be relevant to their mental health.
2. Schools and educational institutions may also request a child/adolescent intake history form to ensure they have all relevant information about the child's academic and emotional needs. This can help them create a supportive environment and provide necessary accommodations or interventions.
3. Legal or government agencies involved in child protection or custody cases may require a child/adolescent intake history form to assess the child's well-being and make informed decisions about their care and custody arrangements.

In conclusion, filling out a child/adolescent intake history form requires providing detailed information about the child's personal, medical, educational, and emotional background. This form is typically used by mental health professionals, schools, and legal agencies to better understand and address the child's needs.

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