Dawn Wilcox, LCSW
COUNSELING SERVICES FOR CHILDREN, ADOLESCENTS & FAMILIES
The Attachment and Trauma Center of Nebraska
Child and Teen Intake Form
OFFICE POLICIES AND GENERAL INFORMATION AGREEMENT
FOR PSYCHOTHERAPY SERVICES
Name_________________________________________ Date of 1st Appointment____________ Therapist _________________________
Date of Birth ______________________
Age _______
Gender: Male ________ Female ________
School________________________________ Grade_______ Key Teacher/School counselor____________________________________
THE PROCESS OF THERAPY/EVALUATION
A typical therapy session lasts 45- 50 minutes, unless planned otherwise. If client is a minor,
parents/guardians are expected to be onsite
while HISTORY
children are within the counseling session and to
MEDICAL
Name of Primarysupervise
Care Physician:
appropriately
any_______________________________________________________________________________________
children within the waiting area, so as to not disturb others. Please be
Physician’s Address:____________________________________________________Physician’s
Phone:_____________________________
considerate
that other therapist will be in counseling sessions. I will always
be available to discuss with
you,
thoughts
or feeling
regarding
and itswith
progress.
Therapeutic
that
be
Manyyour
managed
care companies
require
that wetherapy
have interaction
the client’s
physician toapproaches
coordinate care.
Domay
you give
used
are play
therapy,
therapy,
cognitive-behavioral
us consent
to discuss
yoursandplay
care with the
above named
doctor? (Circle One)therapy,
YES NO family systems, developmental
assessments,
psychoeducational
assessments, and EMDR. If Ms. Wilcox is unable to provide an
Please sign here for
either answer: _____________________________________________________________________________________
appropriate treatment that you would benefit from, she has an ethical obligation to assist you in
obtaining
from an appropriateDate
provider.
Date of last those
medicaltreatments
evaluation:_______________________
of next appointment:______________________________
Current medications being taken:
CONFIDENTIALITY
1)____________________________ Dosage/Freq ____________ Start Date____________Purpose________________________________
All
information disclosed Dosage/Freq
within sessions
and the
records pertaining to those sessions are
2)____________________________
____________
Startwritten
Date____________Purpose________________________________
confidential
between client and therapist. All information revealed within a session may not be further
3)____________________________ Dosage/Freq ____________ Start Date____________Purpose________________________________
revealed to anyone without your written permission, except where disclosure is required by law as
4)____________________________ Dosage/Freq ____________ Start Date____________Purpose________________________________
described in the notice of privacy practices that you received with this form. If the client is a minor, I
Prescribed by: ________________________________________________________________________________________________________
understand that I have the right to general information on issues and progress, however; the Treatment
Provider and the minor child will hold some information shared in this professional relationship in conHas your child
ever been hospitalized
for medical
psychiatric
reasons?
(Circle
one) therapeutic
YES NO
fidence.
To safeguard
confidentiality
andorpreserve
the
integrity
of the
relationship, Dawn
Hospital
Mo/Yr
Reason
Wilcox, LCSW does NOT voluntarily become involved in client legal matters (e.g., custody, visitation,
_________________________________________
___________ ________________________________________________________
litigation
against another, etc.).
_________________________________________ ___________ ________________________________________________________
_________________________________________ ___________ ________________________________________________________
WHEN
DISCLOSURE IS REQUIRED BY LAW
Describe
medical history,
ailments,
or other health
problems
yourwhere
child experiences:______________
Some
ofany
theimportant
circumstances
wherechronic
disclosure
is required
by the
law are:
there is a reasonable
_______________________________________________________________________________________________________________________
suspicion
of child, dependent, or elder abuse or neglect; and where a client presents a danger to self,
_______________________________________________________________________________________________________________________
to
others, to property, or is gravely disabled (for more details see also notice of privacy practices form).
Does your child have a learning or physical disability? (Circle One) YES NO
MAYBE. Describe:_______________________
_______________________________________________________________________________________________________________________
Does your child have a mental health diagnosis? (Circle One)
EMERGENCIES
YES NO
MAYBE. Describe:_____________________________
If_______________________________________________________________________________________________________________________
there is an emergency during our work together, or in the future following termination, where Dawn
Describe LCSW
any other
health problems
or important
history about
your child’s
immediateof
family
close
Wilcox,
becomes
concerned
aboutmedical
your personal
safety,
the possibility
youmembers
injuringand
somerelatives,
chronic
ailments: __________________________________________________________________________________
one
else,including
or about
you receiving
proper psychiatric care, she will do whatever she can within the
_______________________________________________________________________________________________________________________
limits of the law to prevent you from injuring yourself or others and to ensure that you receive proper
medical care. For this purpose, she may also contact the police, hospital, or the person whose
_______________________________________________________________________________________________________________________
name
youchild
have
provided
the biographical
sheet.
Does your
have
any closeon
relatives
(father, mother,
brother, sister, grandparent) who have experienced depression,
anxiety, or other emotional difficulties? Please list: _____________________________________________________________________
_______________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
39 Avenue at the Commons, Suite 106 • Shrewsbury, NJ 07702
14 Bridgewaters Drive • Oceanport NJ 07757
DEVELOPMENTAL and FAMILY HISTORY
In the first two years of life, did your child experience:
___Separation from mother,
___Abuse,
___Neglect,
___Out of Home care,
___Chronic pain,
___Disruption in bonding,
___Chronic Illness,
___Depression of mother,
___Parental Stress
Reached developmental milestones: ___On Time, ___Early, ___Late
How many times has the child moved homes? ___________________
What are five adjectives that describe:
Mother: _______________________________________________________________________________________________________________
Father: _______________________________________________________________________________________________________________
Child: _________________________________________________________________________________________________________________
Parental Relationship: _________________________________________________________________________________________________
Biological Dad:_______________________________ DOB:______ Biological Mom:_________________________________ DOB: ______
Married: __/__/__; Separated: __/__/__; Divorced: __/__/__
Siblings (1st to last) Name: _______________________________________ Age _____
Name: _______________________________________ Age _____
Name: _______________________________________ Age _____
Name: _______________________________________ Age _____
Name: _______________________________________ Age _____
Custodial Adults (if not biological parents): Dad: ________________________________ DOB:_______
Mom: ________________________________ DOB:_______ Date became caretaker: ____________________
People in household, if different from above: ___________________________________________________________________________
________________________________________________________________________________________________________________________
Does father work outside the home? ___ Yes ___ No; Occupation: ________________________________ Hours: _____________
Father’s highest level of education? ______________________
Does mother work outside the home? ___ Yes ___ No; Occupation: ________________________________ Hours: _____________
Mother’s highest level of education? ______________________
If separated or divorced, visitation schedule: ___________________________________________________________________________
Does either parent have legal issues? If YES, Describe __________________________________________________________________
Does your family have any specific spiritual or religious beliefs? If YES, Describe ________________________________________
________________________________________________________________________________________________________________________
List any mental illness or addiction in immediate or extended family (For example: Depression, anxiety, bi-polar disorder,
suicide attempts, alcoholism, drugs, eating disorders, ADHD, Schizophrenia) ____________________________________________
________________________________________________________________________________________________________________________
Have your children witnessed domestic violence? ___Yes ___No. If Yes, describe: _________________________________________
________________________________________________________________________________________________________________________
How is your child disciplined? Please list each method and frequency of use: ____________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
4/2010
14 Bridgewaters Drive • Oceanport NJ 07757
ACADEMIC AND SOCIAL HISTORY
ACADEMIC PERFORMANCE
Highest grade on last report card? _______________________________________
Lowest grade on last report card? ________________________________________
Favorite subjects in school? ___________________________________________________________________________________________
Least favorite subjects? _______________________________________________________________________________________________
Has your child had special testing in school? (If YES, please describe below)
Psychological ____YES
____NO
Learning ____YES
____NO
Vocational ____YES
____NO
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
What would your child life to do about school at this point?
____Quit school ____Graduate from High School ____Go to College
In school, how many friends does your child have? ____ a lot
____a few
____none
Does child have friends in the neighborhood or close cousins they play regularly with? ____YES
____NO
Describe: _____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
How does your child handle anger with peers and family? _______________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
What are your child interests, hobbies and regular activities? ___________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
How much time does your child play on the computer, watch TV or play video games? ___________________________________
________________________________________________________________________________________________________________________
Has your child ever had difficulty with the Police?
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Has your child ever appeared in Juvenile Court?
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Has your child ever been on Probation?
Dates
Reason
Probation Officer
______________
___________________________________________________________
______________________________
______________
___________________________________________________________
______________________________
Has your child ever been employed?
Dates
Employer
Job
______________
___________________________________________________________
______________________________
______________
___________________________________________________________
______________________________
4/2010
14 Bridgewaters Drive • Oceanport NJ 07757
TRAUMA HISTORY
Has your child been verbally abused? ___Yes ___No ___Suspected
Describe: __________________________________________
________________________________________________________________________________________________________________________
Has your child been physically abused? ___Yes ___No ___Suspected Describe: _________________________________________
________________________________________________________________________________________________________________________
Has your child been sexually abused? ___Yes ___No ___Suspected
Describe: __________________________________________
________________________________________________________________________________________________________________________
Other stressors or traumas? ___________________________________________________________________________________________
________________________________________________________________________________________________________________________
CONCERNS, STRENGTHS AND GOALS
Circle the symptoms your child displays and list the number of times per week the symptom is displayed:
Anger
Anxiety
Bedwetting
Acts out sexually
Conduct problems
Controlling
Day defecation
Has unusual sexual knowledge
Day Wetting
Defiance
Depression
Homicidal thoughts or actions
Disassociates
Drug or Alcohol use
Hyperactivity
Masturbates excessively
Hyper-vigilance
Impaired conscience
Isolation
Lack of empathy
Lack of motivation
Lethargy
Low impulse control
Plays out violent themes
Low self-esteem
Lying
Nightmares
Plays out sexual themes
Obsesses
Over/Under eating
Phobias
Peer Problems
Phobias
Running away
Shy
Self-mutilating
Sleeping problems
Suicide talk
Stealing
Tantrums
Somatic symptoms: headaches, stomachaches, etc
OTHER Concerns: _____________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Has the child experienced any significant loss? If Yes, Describe: _________________________________________________________
________________________________________________________________________________________________________________________
What do you view as your child’s major strengths and positive traits? ___________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Describe your goals for your child’s therapy: ____________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
What else is important for your therapist to know about your child and your family? _____________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Thank you for taking the time to complete this form. This information helps us have a strong start in helping your family.
4/2010
14 Bridgewaters Drive • Oceanport NJ 07757