Parent Intake Form Date: ______________

PERSONAL INFORMATION

Child’s name:
__________________________________________________________________________

Age: __________ Sex: __________ Birthday: __________

Address: _____________________________________________________________________________

Religion (if applicable):

__________________________________________________________________

Parents are currently: ___ Married ___ Divorced ___ Separated ___ Others (specify):
__________

Name of person completing the form:

______________________________________________________

Relationship to the Child:

________________________________________________________________

Address: _____________________________________________________________________________

Contact Number/s: ___________________________ E-mail address: ___________________________

Religion (if applicable):

__________________________________________________________________

Name of other parent/legal guardian:

______________________________________________________

Relationship to the Child:

________________________________________________________________

Address: _____________________________________________________________________________

Contact Number/s: ___________________________ E-mail address: ___________________________

Religion (if applicable):

__________________________________________________________________

Are there other relatives or adults that are important caretakers of the child (i.e. stepparent, significant
other, grandparent)? ____Yes ____No

If yes, indicate the following:

Name of person: _________________ Age: _______ Relationship to the child: ________________

Name of person: _________________ Age: _______ Relationship to the child: ________________

Name of person: _________________ Age: _______ Relationship to the child: ________________

Does the child have any siblings? ____Yes ____No

If yes, indicate the following:

Name of sibling: _______________________________ Sex: ________ Age: ________

Name of sibling: _______________________________ Sex: ________ Age: ________

Name of sibling: _______________________________ Sex: ________ Age: ________

ACADEMIC INFORMATION

Is the child currently attending school? ____Yes ____No

If yes, indicate the following:

Name of school: ___________________________ Current Level of the child: _________________

Has your child received any special education assistance? ____Yes ____No

If yes, indicate the following:

Name of school: ______________ Date: ______ Outcome/Comments: _______________________

Name of school: ______________ Date: ______ Outcome/Comments: _______________________

Name of school: ______________ Date: ______ Outcome/Comments: _______________________

Does the child have any favorite subjects? ____Yes ____No

If yes, please indicate:

___________________________________________________________________

Does the child experiences difficulty in any subjects? ____Yes ____No

If yes, please indicate:

___________________________________________________________________

CHILD’S DEVELOPMENT

1. Were there any complications with the pregnancy or delivery of the child? _____Yes ___ No

If yes, please indicate:

____________________________________________________________

2. Did your child have health problems at birth? _____Yes _____ No

If yes, please indicate:

____________________________________________________________
 3. Did your child experience any developmental delays (i.e., toilet training, walking, talking, etc.,)?
_____Yes ___ No ___ Not sure

If yes, please indicate:

____________________________________________________________

4. Did your child experience any kind of abuse (i.e., emotional, physical, or sexual)
_____Yes ____ No ____ Not sure

If yes, please indicate:

____________________________________________________________

CLIENT HISTORY

1. Has your child ever received counseling, psychological, alcohol or drug treatment before?
_____Yes _____ No
If yes, please indicate the following:
a. Name of clinic/organization the treatment was conducted: ___________________________
b. Approximate date of counselling/treatment: ______________________________________
c. Please provide us an insight on the results of the treatment:
___________________________________________________________________________
___________________________________________________________________________

2. Did your child have a previous mental diagnosis: ___Yes ____No

If yes, please indicate:
____________________________________________________________

3. Has your child taken any medications for a mental health concern? ___Yes ____No
If yes, please indicate the following:

Name: ___________________ Dates Taken: __________ Was it helpful? (Yes/No):

________

Name: ___________________ Dates Taken: __________ Was it helpful? (Yes/No):

________

Name: ___________________ Dates Taken: __________ Was it helpful? (Yes/No):

________

4. List the name of child’s primary care physician:

______________________________________________________________________________
______________________________________________________________________________
5. List any current medical illness or health-related concerns:

______________________________________________________________________________
______________________________________________________________________________
 6. Indicate any current medications of the child:

______________________________________________________________________________
______________________________________________________________________________

7. List any family history of mental illness or chemical dependency:

______________________________________________________________________________
______________________________________________________________________________

REFERRAL INFORMATION

Referral Source (if there’s any, indicate the following):

Name: ___________________________________ Relationship to the Child: _____________________

Purpose of Referral: ________________________________________

CONCERNS ABOUT THE CHILD

1. What concerns you most with the child’s current problem behavior:
______________________________________________________________________________
______________________________________________________________________________
2. When did these problems start?
______________________________________________________________________________
______________________________________________________________________________

3. How long has this been a problem?

______________________________________________________________________________
______________________________________________________________________________

4. Kindly indicate any other events happened in the child’s life at the onset of the problem?
______________________________________________________________________________
______________________________________________________________________________
5. Overall, how would you rate the impact of the above-mentioned problems with the child’s
performance at school, social interaction, and daily functioning?

(Mildly disruptive) 1 2 3 4 5 6 7 8 9 10 (Severely disruptive)

Kindly describe:
______________________________________________________________________________
______________________________________________________________________________

CURRENT HABITS

Has your child experienced recently or currently experienced any of the following?

YES NO COMMENTS
Suicidal Thoughts
 Difficulty sleeping
Suicide attempts
loneliness, or hopelessness
Self-inflicted injury behaviors
Crying often
Frightening dreams/thoughts
Social Withdrawal
Aggressive behaviors
Difficulty completing tasks
Difficulty expressing feelings
Nervousness, anxiety, or worry
Difficulty remembering
Difficulty relaxing
Difficulty concentrating
Difficulty interacting with others
Fidgeting
Physically Aggressive
Anger Issues
Trauma Flashbacks
Problems with eating

RELATIONSHIPS

Kindly describe the relationship of the child with the following, if applicable:

a. Biological Mother:
___________________________________________________________________________
b. Biological Father:
___________________________________________________________________________
c. Step-parents:
___________________________________________________________________________
d. Legal guardians:
___________________________________________________________________________
e. Siblings:
___________________________________________________________________________
f. Extended family:
___________________________________________________________________________
g. Classmates:
___________________________________________________________________________
h. Friends:
___________________________________________________________________________

STRESSFUL LIFE EVENTS

Kindly describe any significant or stressful life events that the child has been experiencing in terms of
the following, if applicable:

a. School Adjustments: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________

______________________________________________________________________________

b. Abuse: ___ N/A ___ Yes (if yes, please describe):

______________________________________________________________________________

______________________________________________________________________________

c. Bullying: ___ N/A ___ Yes (if yes, please describe):

______________________________________________________________________________

______________________________________________________________________________

d. Academic difficulties: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________

______________________________________________________________________________

e. Self-injuries: ___ N/A ___ Yes (if yes, please describe):

______________________________________________________________________________

______________________________________________________________________________

f. Death or illness of a loved one/pet: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________

______________________________________________________________________________

g. Family problem: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________

______________________________________________________________________________

Others (Please Specify):

_____________________________________________________________________________________
_____________________________________________________________________________________

Other Information:

What are the positive attitudes and/or strengths of the child? What attitude/s and activities helped the
child solved problems in the past?
_____________________________________________________________________________________
_____________________________________________________________________________________

What are the child’s interests/hobbies/habits?

_____________________________________________________________________________________
_____________________________________________________________________________________

What are the child’s difficulties/weaknesses?

_____________________________________________________________________________________
_____________________________________________________________________________________

Describe ways as to how the family is adjusting with the current situation of the child.

_____________________________________________________________________________________
_____________________________________________________________________________________

Is your religion a source of support for you and/or your child?

_____________________________________________________________________________________
_____________________________________________________________________________________

Are spiritual beliefs important in assisting you and your child during this time? (if yes, please describe):

_____________________________________________________________________________________
_____________________________________________________________________________________

Are there cultural and/or ethnic values or beliefs about health that are important to you? (if yes, please
describe):

_____________________________________________________________________________________
_____________________________________________________________________________________

What are your expectations for the child to achieve in his/her personal life?

_____________________________________________________________________________________
_____________________________________________________________________________________

What are the possible goals that you would like your child to achieve in this therapy?

_____________________________________________________________________________________
_____________________________________________________________________________________

Do you have any concerns/problems that you want to mention? If there are any, feel free to mention
below:

_____________________________________________________________________________________
_____________________________________________________________________________________
 I, ______________________ have provided the above-mentioned information for _______________
(name of child) as his/her ___________________ (relationship to the child) and to be used solely for the
course of the treatment. I give my consent to use this information in the course of the therapeutic
process. All information provided are all correct and aligned with all of my other existing records in my
affiliations. I should be informed of any possible use of the provided information outside this therapy.

Name of child client: ________________________________ Date: ______________________________

Name of person who completed the form: ________________________ Signature: ______________

Name of parent/guardian: _____________________________________ Signature: ______________