Please print this form and complete it by hand. For a child or teen client, a parent or guardian completes this form about the child; an adult client completes it about themselves. Do not fill it out or submit it online, and do not email the completed form — bring it to your first session or upload it through the secure client portal at [Client Portal]. This protects your family’s private health information.
Child / Client Information
Child’s / client’s full name:
Date of birth: Age: Pronouns:
School: Grade:
Address:
City: State: ZIP:
Parent / Guardian & Household
Parent / guardian name(s):
Relationship to child: Has legal custody? Yes No
Phone: May I leave a voicemail? Yes No
Email:
Okay to send appointment reminders by: Phone Text Email None
Who does the child live with?
Siblings (names / ages):
Are the parents together, separated, or divorced? Any custody or safety orders I should know about? Yes No
Emergency Contact
Name:
Relationship to child: Phone:
How Did You Hear About This Practice?
What Brings Your Child to Therapy?
Please check any areas of concern:
- Worries or anxiety
- Separation anxiety / school refusal
- Sadness or low mood
- Grief or loss
- Trauma or a scary experience
- Tantrums, anger, or meltdowns
- Defiance / behavior at home or school
- Focus, attention, or hyperactivity
- Family changes (divorce, move)
- Friendships / social skills
- Bullying
- Self-esteem
- Identity (incl. LGBTQ+)
- Sleep difficulties
- Eating or body image
- Substance use (teens)
- Other
In your own words, what would you like help with for your child?
How long has this been a concern? What have you already tried?
Development & School
Any concerns during pregnancy, birth, or early development (walking, talking, milestones)? Yes No
If yes, please describe:
How is your child doing academically?
Any IEP, 504 plan, or school support services? Yes No Any diagnoses (e.g. ADHD, autism, learning)?
Mental Health History
Has your child been in therapy or counseling before? Yes No
If yes, when, with whom, and was it helpful?
Has your child ever been hospitalized or seen in an ER for a mental health concern? Yes No
If yes, please describe:
Has your child ever expressed thoughts of harming themselves or not wanting to live? Currently In the past Never / not that I know of
If current or past, please share what you know (we will discuss together):
Has your child ever intentionally hurt themselves (self-harm)? Yes No Not sure
Medical History & Current Medications
Child’s pediatrician / primary care provider (name / practice):
Significant medical conditions, past or present:
Current medications (including psychiatric medications and supplements):
| Medication | Dose | Prescribed by | For |
|---|---|---|---|
Is your child currently seeing a psychiatrist or other prescriber? Yes No
If yes, who?
Substance Use (Teens)
For teen clients: does your teen use any of the following? Please note what you know. (Your teen and I may also discuss this privately; please see the confidentiality section of the Informed Consent regarding a minor’s right to consent to substance-use counseling.)
Alcohol: Cannabis:
Nicotine / vaping: Other:
Has substance use ever caused problems or concern? Yes No Not applicable
Family Mental Health History
Has anyone in the family experienced depression, anxiety, ADHD, substance use problems, or other mental health conditions?
Social & Family Background
Who lives in the home with your child?
Who are your child’s main sources of support (family, friends, coaches, faith community)?
Anything about your family’s cultural background, faith, or identity that is important for me to know?
Strengths & Interests
What does your child enjoy or do well (activities, interests, talents)?
What helps your child calm down or feel better when things are hard?
Goals for Therapy
If therapy goes well, what would be different for your child and your family?
Signature
The information provided on this form is accurate to the best of my knowledge.