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?
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Kerry Williamson, MA, LPC-S, LMFT-S, CST
Carolyn Dixon, MSW, LCSW
Rachelle Honohan, MSW, LCSW-S
Regina Gray, MS, LPC
Nicole Parker, MA, LPC
Linlee Carbajal, MS, LPC
Julie O'Brien, MA, LPC-Associate Supervised by: Kerry Williamson, MA, LPC-S, LMFT-S, CST
Hannah Park, MA, LPC-Associate Supervised by: Kerry Williamson, MA, LPC-S, LMFT-S, CST
Catherine Cain, MSW, LMSW, Supervised by Melissa Gould, LCSW-S
Identifying Information
Your Full Name
*
First Name
Last Name
Nickname (if any)
Date of birth
*
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Month
-
Day
Year
Date
Age
Gender
Race & Ethnicity
School Attending
Grade
Name(s) of Parent(s) / Guardian(s)
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone
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Area Code
Phone Number
Home Phone
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Area Code
Phone Number
May we call you at the phone number(s) provided above? Check all that apply.
Yes, you can call my cell phone
Yes, you can call my home phone
Please do not call me
May we leave you a voicemail at the phone number(s) provided above? Check all that apply.
Yes, you can leave a voicemail on my cell phone
Yes, you can leave a voicemail on my home phone
Please do not leave a voicemail
Do you attend church regularly?
Yes
No
Are religious or spiritual issues important in your life?
Yes
No
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?
Yes, I have gained weight.
Yes, I have lost weight.
My weight is the same.
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?
Yes
No
For which types of foods?
How would you rate your diet?
Very Healthy
Healthy
Average
Needs Improvement
Poor
Are you currently taking medications?
Yes
No
If you are taking medications, please list what you know you are taking.
For Adolescent Girls
Are you pregnant?
Yes
No
Unsure
Do you have a regular menstrual cycle?
Yes
No
Not of age
Have you ever terminated a pregnancy?
Yes
No
Have you ever miscarried?
Yes
No
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."
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?
Yes
No
When and what for?
How did it go?
Have you experienced any type of trauma? Check all that apply.
Physical Abuse
Sexual Abuse
Psychological/Emotional Abuse
Human Trafficking
Witnessed Domestic Violence
Car Crash
Dating Violence
Robbery or Assault
Bullying
Witnessed Homicide
Death of Close Family Member or Friend
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.
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?
Yes
No
What is the friend's age?
Are you currently employed?
Yes
No
Where?
Please give any additional information that you believe would be helpful for me to know.
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