• ALCS Child Intake Form (Parent/Guardian)

    Thank you for choosing Abundant Life Counseling Services, P.A. So that we can better assist your teen, please fill out this form as fully and openly as possible. All information is held in strictest confidence within legal limits. If certain questions do not apply, you can leave them blank.

  • Identifying Information

  • Date of birth*
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    2 digit month, 2 digit day, 4 digit year
  • Gender
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  • May we call you at the phone number(s) provided above? Check all that apply.
  • May we leave you a voicemail at the phone number(s) provided above? Check all that apply.
  • May we email you at this email address?*
  • Does the child attend church regularly?

  • Personal Concerns

  • Behaviors of Concern

  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Has the child had any previous professional assistance with the problems stated here?*

  • Family History

  • Is your child adopted?
  • Are they aware of the adoption?
  • Has the child ever been in foster care?
  • Please list all family members currently living at home or closely connected with the family. Indicate their ages, relationship to this minor and their school grade or occupation.
    Rows

  • Social Development and Peer Relationships

  • When your child chooses friends, are they... (pick all that apply)

  • Does the child prefer the company of adults to other children?
  • Does the child have at least one best friend?

  • Emotional Development

  • Please check any and all that family members, teachers or others have used to characterize your child:

  • Has your child experienced any type of trauma? Check all that apply:

  • School History

  • Has your child...
  • Has your teen had any remedial help or special education services in school or privately?

  • Health Information

  • Was your child full-term?
  • Did your child meet all their development milestones appropriately?
  • Do they experience food cravings?
  • Has your child gained or lost weight in the past three months?
  • How would you rate your child's diet?
  • Are they currently taking medications?
  • If so, please complete the following.
    Rows
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  • Date of last physical exam
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    2 digit month, 2 digit day, 4 digit year
  • Date of last routine check-up
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    2 digit month, 2 digit day, 4 digit year
  • Is your child currently using any drugs or alcohol for recreational purposes?
  • Please list drug and/or alcohol use.
    Rows

  • Emergency Contact

    Whom should we contact in case of emergency?
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  • Should be Empty: