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CHILD CLINICAL INTAKE
Please fill out these questions as best you can prior to our first Intake appointment. This
information is vital to the treatment process for your child and family. Thank you in advance for
your time and commitment to the well-being of your child.
DATE: Click or tap to enter a date.
REFERRAL INFORMATION
How did you learn about Healthy Roots Counseling? Choose an item.
Please list the specific name and address, if known, so we can send a personal thank you
for their referral: Click or tap here to enter text.
DEMOGRAPHIC INFORMATION
Child’s Name: Click or tap here to enter text.
Nickname: Click or tap here to enter text.
DOB: Click or tap to enter a date. Age: Click or tap here to enter text. Gender: Click or tap here
to enter text.
Address: Click or tap here to enter text.
City
State
Zip
Home Phone: Click or tap here to enter text. Is it okay to leave message on answering machine?
☐Y
☐N
Cell Phone: Click or tap here to enter text. Is it okay to leave message on answering machine?
☐Y
☐N
*We cannot guarantee confidentiality when we are communicating via cell phone, cordless phone, fax, email or
computer. These devices could compromise confidentiality. By understanding the inherent risks of the
aforementioned devices, you can make an informed choice about when/where/how to use these tools.
6400 W. 110th St., Ste 203
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]
2
Who may we contact in the event of an emergency?
Name: Click or tap here to enter text. Phone Number: Click or tap here to enter text.
Relationship to child: Click or tap here to enter text.
PARENT INFORMATION
FATHER: How would you describe your child’s relationship with his/her father? Choose an item.
Father’s Name: Click or tap here to enter text. DOB: Click or tap to enter a date.
Email Address: Click or tap here to enter text.
Relationship to Child: Choose an item.
If adopted, age of child at adoption: Click or tap here to enter text.
Relationship Status: Choose an item. Date of divorce: Click or tap to enter a date.
Years married: Click or tap here to enter text.
Highest Grade Level Completed Click or tap here to enter text.
Employment: Click or tap here to enter text. Years employed: Click or tap here to enter text.
Typical work day hours: Click or tap here to enter text. Number of hours/week: Click or tap
here to enter text.
MOTHER: How would you describe your child’s relationship with his/her mother? Choose an
item.
Mother’s Name: Click or tap here to enter text. DOB: Click or tap to enter a date.
Email Address: Click or tap here to enter text.
Relationship to Child: Choose an item.
If adopted, age of child at adoption: Click or tap here to enter text.
Relationship Status: Choose an item. Date of divorce: Click or tap to enter a date.
Years married: Click or tap here to enter text.
Highest Grade Level Completed Click or tap here to enter text.
Employment: Click or tap here to enter text. Years employed: Click or tap here to enter text.
Typical work day hours: Click or tap here to enter text. Number of hours/week: Click or tap
here to enter text.
6400 W. 110th St., Ste 203
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]
3
Describe any additional job circumstances of the parents that may be important: Click or tap
here to enter text.
Has either parent ever received counseling? ☐ Y ☐ N
problem and outcome Click or tap here to enter text.
If yes, briefly describe presenting
How would you describe your marriage during the past six months? Choose an item.
How would you describe your marriage during the last month? Choose an item.
If parents are divorced, please list who has legal guardianship: Choose an item.
Briefly explain any special living circumstances (foster care, custody arrangements, visiting
rights, etc.): Click or tap here to enter text.
FAMILY SYSTEM
Household members (Please list below all individuals living in the same home as the child):
Name
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Age
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Relationship to Child
How would you
describe your child’s
relationship with them?
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Has there been any significant stressors within the family? Please choose “c” for child or “f” for
family.
Choose an item. Medical complications
Choose an item. Death of a loved one
Choose an item. Frequent moves
Choose an item. Deployment
Choose an item. Change of schools
Choose an item. Divorce
Choose an item. Financial stressors
Choose an item. Significant injuries
Choose an item. Car accident
Choose an item. Parent separation
Choose an item. Legal problems
Choose an item. New siblings
6400 W. 110th St., Ste 203
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]
4
Choose an item. Parents remarried
Choose an item. Change in living situation
Choose an item. Natural disaster
Choose an item. Witnessed abuse/violence
Please list any other recent changes or stressors within the family: Click or tap here to enter
text.
EDUCATIONAL BACKGROUND
Current School: Click or tap here to enter text. Teacher: Click or tap here to enter text.
Grade Level: Click or tap here to enter text.
Average Grades: Choose an item.
Does your child have an Individual Education Plan (IEP) or 504 plan? ☐IEP
☐504 plan
If yes, please briefly explain the purpose of the plan. Click or tap here to enter text.
List any behavioral, academic, or social concerns in school: Click or tap here to enter text.
Is your child involved in any specialized services at school? (i.e. speech therapy, reading groups,
etc.) Please explain: Click or tap here to enter text.
Do you have concerns with your child’s peer interactions? ☐Y ☐N
Click or tap here to enter text.
If yes, please describe
DEVELOPMENTAL HISTORY
Any medical problems during pregnancy: ☐Y ☐N
to enter text.
If yes, please describe: Click or tap here
Were there any complications during the labor and delivery and/or as a newborn? Check all that
apply.
☐Maternal drug usage
☐Premature birth
☐NICU (how long? Click or tap
here
to enter
text.)
☐
Health
complications
☐Difficult temperament as a newborn
☐Frequent ear infections
☐Unclear speech
☐Difficultly being soothed
If yes, please briefly describe: Click or tap here to enter text.
Any infant or toddler developmental issues? Check the box if your child did not meet his/her
milestone appropriately.
☐Imaginary play
☐Sitting up
☐Crawling
☐Standing
6400 W. 110th St., Ste 203
☐Walking
☐Feeding Self
☐Talking
☐Toilet Training
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]
5
Does your child currently have any developmental delays? ☐Y
Click or tap here to enter text.
☐N
If yes, please explain
PSYCHIATRIC HISTORY
Has your child ever attended counseling previously? ☐ Y
Therapist Name/Agency
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text.
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text.
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text.
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text.
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☐N
Date
Presenting Concern
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Was your child given a diagnosis by the therapist/psychiatrist? ☐Y
☐N
If yes, please list the diagnosis: Click or tap here to enter text.
Was therapy helpful? ☐Y
☐N
Please explain. Click or tap here to enter text.
Please list any other professionals your child is currently working with (i.e. school counselor,
occupational therapist, speech therapist, nutritionist, etc.): Click or tap here to enter text.
MEDICAL HISTORY
Does your child have any health/medical issues? ☐ Y
Click or tap here to enter text.
☐ N If yes, please indicate below:
Date of last medical exam: Click or tap here to enter text.
enter text.
Physician: Click or tap here to
Phone Number: Click or tap here to enter text.
Does your child have any drug or food allergies? ☐Y ☐N
here to enter text.
If yes, please list: Click or tap
Is your child taking any medications for physical or emotional health? ☐Y ☐N
Medication
6400 W. 110th St., Ste 203
Condition
Leawood, KS 66211
913.735.6093
Date Prescribed
www.healthyrootscounseling.com
Prescribing Physician
[email protected]
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date.
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date.
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date.
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date.
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PRESENTING CONCERNS
Please describe briefly the concern or situation which led you to seek therapy services at this
time: Click or tap here to enter text.
How long have these concerns been present? Click or tap here to enter text.
GOALS FOR THERAPY
What do you hope to accomplish for your child and family as a result of therapy? Click or tap
here to enter text.
Please add any additional information that is important for your therapist to know: Click or tap
here to enter text.
Thank you for taking the time to fill out these important questions regarding your child and
family. We will review these questions in detail during out first Intake session along with any
questions or concerns you might have regarding this information. We look forward to meeting
with you soon!
Best Regards,
Healthy Roots Counseling
6400 W. 110th St., Ste 203
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]
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6400 W. 110th St., Ste 203
Leawood, KS 66211
913.735.6093
www.healthyrootscounseling.com
[email protected]