Adolescent Intake Form for Adolescent (ALCS)

ALCS Adolescent Intake Form (Adolescent)

Thank you for choosing Abundant Life Counseling Services, P.A. This form is for you, the adolescent, to fill out. I want you to give me all the information you want me to know. It will allow me to better assist you. Please be as open as you can in giving me information. If you are unsure of something, you can skip it and we can talk about it later. All information is held within strictest confidence within legal limits. If certain questions do not apply to you, please leave them blank.
Who is your ALCS counselor?
Identifying Information
Your Full Name

First NameLast Name
Nickname (if any)
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Gender
Race & Ethnicity
School Attending
Grade
Name(s) of Parent(s) / Guardian(s)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Home Phone

Area CodePhone Number
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.
Do you attend church regularly?
Are religious or spiritual issues important in your life?
Name and denomination of your church
Health Information
How would you rate your health?
Have you gained or lost weight in the past three months?
How much weight was gained / lost?
Ex: 10 lbs gained
Please list all important present or past illnesses, injuries or handicaps:
How many hours do you sleep each night?
Do you experience food cravings?
For which types of foods?
How would you rate your diet?
Are you currently taking medications?
If you are taking medications, please list what you know you are taking.
For Adolescent Girls
Are you pregnant?
Do you have a regular menstrual cycle?
Have you ever terminated a pregnancy?
Have you ever miscarried?
Personal Concerns
Do you have any concerns about yourself?
Do you do things you wish you could change?
What do you believe your three greatest strengths are?
What do you believe your three greatest weaknesses or areas of improvement are?
Personal Concerns Checklist

Rate how much of a concern each item is for you: "not a concern," "sometimes a concern," or "major concern."

Rows	Not a concern	Sometimes a concern	Major concern
Feeling accepted by my peers/friends
Learning how to trust others
Getting along with my parents
Getting along with my siblings
Getting along with other family members
Getting a clear sense of what I value
Dealing with sexual/gender feelings and/or concerns
Worrying about my future
Trying to decide on a career
Dealing with alcohol
Dealing with drugs
Dealing with problems at school
Dealing with how I feel about myself
Thinking I want to die
Dealing with social media/use of technology

Additional concerns I'd like to talk about:
Have you been to counseling before?
When and what for?
How did it go?
Have you experienced any type of trauma? Check all that apply.
If so, please provide a brief description.
Family History
Mother's Name
Mother's Occupation
Father's Name
Father's Occupation
If your parents are separated or divorced, how old were you when this happened?

Please list all family members currently living at home or closely connected with the family, as well as any siblings living outside the home. Indicate their ages, relationship to you and their school grade or occupation.

Rows	Name	Age	Relationship	Grade/Occupation
1
2
3
4
5
6
7
8

Social Development and Peer Relationships
What special interests, hobbies, sports, and games do you enjoy, both in and after school?
Do you have at least one best friend?
What is the friend's age?
Are you currently employed?
Where?
Please give any additional information that you believe would be helpful for me to know.
Should be Empty:

ALCS Adolescent Intake Form (Adolescent)

Identifying Information

Health Information

For Adolescent Girls

Personal Concerns

Personal Concerns Checklist

Family History

Social Development and Peer Relationships