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Intake Assessment Information - Youth

Blue Water Counseling
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
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Child Client
Birthdate:
Gender:
What are the concerns about your child for which you are seeking assistance?
Family Information
Race:
Cultural Considerations:
Family History of Mental Health or Substance Abuse Problems:
Explain:
Child's Parents
Married   Divorced   Separated  
Never Married     
Parents
  Name: Age: Deceased: Occupation: Highest Grade Level:
Birth Father
Birth Mother
Step Father
Step Mother
Adopted Father
Adopted Mother
Annual Family Income:
Language Spoken:
Family Size:
Client's Brothers and Sisters
  Name Age Occupation Education Deceased Date & Cause Relationship
1.
2.
3.
4.
5.
Other Household Members
  Name Age Sex Occupation or Grade Relationship
1.
2.
3.
4.
5.
Who does your child live with currently?
Who did your child live with previously?
Describe your child's relationship with:
  Description
Parents:
Siblings:
Extended Family Members:
Teacher(s):
Other Children:
List any family members you wish to have involved in treatment and why:
Physical Description
Height:
Weight:
Recent Gains or Losses
Other distinguishing features:
Does your child have any physical impairments or disabilities? If so, explain:
Are physical characteristics or body image a concern? Explain:
Education
Name of Current School:
Current grade:
Name of Teacher:
Name of School Social Worker:
Special Education?
If yes, type of Spec Ed certification:
Did not complete school?
Last school attended:
Grade Completed:
Is or was your child’s school performance a concern?
Explain:
Can your child read well?
Employment
Is your child currently employed?
If yes:
Name of employer?
Comments:
Spiritual Information
Is spirituality an area of support or strength for your child?
Religion:
Catholic   Jewish   Islamic  
Protestant   Other:    
Is this an area of concern?
Explain:
Sexual Functioning / Sexuality / Gender Identity
Is this an area of concern?
Explain:
Community Services Received Currently or Previously
Previous Mental Health Counseling / Substance Abuse Treatment:
  Where When
1.
2.
3.
4.
5.
Was previous counseling/treatment helpful to your child in the past?
Previously or Presently Attended Support Groups
  Name Description
1.
2.
3.
4.
5.
Was support group attendance helpful?
Substance Use
Does your child use illegal or unprescribed drugs including alcohol?
If yes, explain which drugs, amount and frequency:
Does your child misuse prescription drugs?
If yes, explain which drugs and how they are misused:
Has anyone ever expressed concern with your child's use of alcohol or other drugs?
If yes, explain:
Does your child smoke cigarettes now or in the past?
If yes, explain time period, amount and frequency:
Social Life
Describe your family's strengths:
Describe your child's support system:    (ie. family, friends)
Describe your child's recreational interests:
Describe any relationship problems with friends/peers:
Health History
Primary Physician:
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone:  
(Business)
   (Cell)
Email:
Date of last physical exam:
Pharmacy (include Street, City):
Phone:
Medications:    List all current prescriptions, regularly taken over the counter meds and supplements
Are there concerns about medications including drug allergies?
Explain:
Health Problems
  Status Family History
Allergies
Anorexia
Asthma
Broken Bones
Communicable Diseases
Diabetes
Fainting/Dizzy
Hearing Problems
Heart Disease
High/Low Blood Pressure
High/Low Blood Sugar
Liver Disease, Jaundice
Major Injuries
OB/Gyn Problems
Obesity
Seizures/Epilepsy
Stomach or Intestinal Problems
Thyroid Problems
Ulcer
Vision Problems
Assistive Technology Needed?
Comments:
Developmental Issues    List any developmental skills that your child accomplished ahead of or behind others the same age, (examples: walking, talking, reading, etc.)
Does your child have generally good nutrition habits?
Special diet required:
Abuse History
Has your child experienced physical, sexual or emotional abuse?
Explain:
Legal History
Does your child have any history of legal charges?
Explain:
Is your child currently on probation?
Probation officer's name:
Is treatment court ordered?
Are there custody / visitation concerns?
Explain:
Other Relevant Concerns
Please describe any other relevant concerns:
Notes
Form Updates
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