CHILD AND ADOLESCENT INTAKE FORM Stephanie

Child's Name

First NameLast Name

Birth Date

MonthDayYear

REASONS FOR SEEKING EVALUATION OR THERAPY

Please provide a short description of the problems or concerns that have brought you to Child Development Associates:

FAMILY HISTORY

Parents are:

If parents are not living together, what is the custody arrangement?

Who primarily meets the daily child care and/or parenting needs?

Please list all the people living in the household:

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child
Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

If siblings or other immediate family are living outside the home, please list their names and ages:

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child
Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

First Name   Last Name   Age   Relationship to child   Occupation/School & Grade

Parents’/Guardians’ current work statuses (e.g., full-time/part-time/not working; working from home, out of the house, hybrid model):

Family Cultural Background:

Religion(s) practiced in the home (if any):

Primary language spoken in the home:

Other languages:

Family Stressors: Please check all that apply.

Rows	Past	Current
Marital conflict
Custody disputes
Financial problems
Job loss/changes
Parent using alcohol/drugs
Sibling emotional/behavioral problems
Legal issues
Housing problems
Significant moves
Death of relative or friend
Death of pet
Family accident or illness
Sibling rivalry/major conflict
Other stressors

If other stressors, please explain:

DEVELOPMENTAL HISTORY

How was the mother’s overall health during pregnancy?

Please describe any complications during pregnancy:

Please describe any labor, delivery, and/or birth complications:

As an infant or toddler, did you have any concerns with the following?

Please describe any concerns:

Have you or anyone else ever had concerns about this child’s development (i.e., fine motor, gross motor, speech/language, social/emotional)?

If yes, please specify the concerns and your child received any services for these concerns (e.g., occupational therapy, speech therapy):

EDUCATIONAL HISTORY

Preschool:

Elementary School:

Middle School:

High School:

What are your child’s academic strengths?

Has your child had difficulty with any of the following? Please check all that apply.

Rows	Past	Current
Reading
Arithmetic
Spelling
Writing
Time management
Attendance
Disciplinary actions

If any concerns, please explain:

RELATIONSHIP DEVELOPMENT

Please check items that describe your child.

Rows	Past	Current
Prefers to be alone
Is alone a lot, but dislikes it
Is shy or timid
Has few friends
Has many friends
Plays/Spends time with “problem kids”
Is picked on/teased/bullied
Is oversensitive
Is more interested in objects than people
Poor relationships with teacher
Prefers spending time with adults
Is demanding and/or bossy
Fights with others
Teases/ bullies others
Plays/ Spends time with younger kids
Plays/ Spends time with older kids
Poor relationships with peers
Conflict with parents/step-parents
Excessive conflict with siblings

EMOTIONAL BEHAVIOR CHECKLIST

Please check items that describe your child

Rows	Past	Current
Crying, sadness, depression
Loss of enjoyment in activities
Expressing a wish to die
Bedtime fears, won't sleep
Panics
Bites nails
Fidgets, unable to stay still
Unusual fears or phobias
Anxious, nervous
Is overly concerned about things
Twitches or unusual movements
Vocal/motor tics (e.g., repetitive eye blinking, throat clearing, facial movements, noises, etc.)
Withdrawn
Nightmares, night terrors
Low self-esteem
Injuries self (e.g., cutting, head banging)
Vomits intentionally
Low motivation
Problems with authority
Swears or uses obscene language
Easily annoyed by others
Blames others for own mistakes
Temper, Irritability, anger
Has threatened/attempted suicide
Disobedience
Argues a lot
Defiant
Has frequent tantrums
Wanting to run away
Sneaks out at night
Stealing
Lying
Hurts people or animals
Destroys property
Drug/Alcohol use
Repeats unnecessary act
Has rituals, habits, superstitions
Gorges or binge eats
Fasts to lose weight
Sleepwalking
Tiredness, fatigue
Restless sleep, wakes frequently
Trouble going to sleep
Sleeps too much
Poor appetite
Under or overweight
Over-activity
Frequently acts without thinking
Doesn't finish things
Disruptive
Short attention span, easily distracted
Daydreams, fantasizes
Is forgetful
Does not listen
Sexual problems
Concerns about identity
Hallucinations (i.e., hearing/seeing things that are not there)
Strange or unusual behavioral
Disorientation
Bedwetting/daytime wetting
Soiling (pooping) in pants

Engages in behavior that could be dangerous to him/herself

Describe

Engages in behavior that could be dangerous to others

Describe

Other concerning behaviors:

Describe

PRIOR TREATMENT

Has your child ever received mental health services (evaluation or treatment)?

If yes, please provide any diagnosis given and describe services:

Did you find it helpful?

CHILD’S MEDICAL HISTORY

When was your child’s last physical examination?

How would you describe your child/adolescent’s health?

How is his/her?

Hearing?

Vision?

Speech & language?

Fine motor coordination?

Gross motor coordination?

Has your child/adolescent ever had chronic health problems (e.g., asthma, diabetes, allergies, heart condition)?

If yes, please specify and provide age of onset:

Has your child/adolescent had any medical problems aside from the usual childhood illnesses, including injuries (e.g., concussions)?

If yes, please specify:

If your child/adolescent has ever been hospitalized, what was it for?

If your child/adolescent has ever had surgery, what was it for?

Is your child/adolescent currently taking any medication?

If yes, what medication(s):

This child/adolescent’s usual bedtime is at: time School nights time Weekends/vacation.

Describe this child sleep patterns or habits: Check all that apply.

Describe this child’s eating habits:

FAMILY MEDICAL HISTORY

Please identify any illness, medical condition, or disability that any member of the immediate family has had (e.g., heart disease diabetes, cancer).

Please note any family history of substance abuse, mental illness, or learning disability (e.g., anxiety,depression, suicide, hospitalizations in mental institutions, abuse).

OTHER INFORMATION

What are your child’s favorite activities?

Is your child currently employed or work during school breaks?

If yes, where and how many hours/week?

Do you have concerns about your child's technology use?

If yes, please explain:

What disciplinary techniques do you usually use when your child behaves inappropriately?

Which disciplinary techniques are usually effective?

What type of disciplinary techniques are usually ineffective?

What have you found to be the most satisfactory ways of helping your child?

What are your child’s strengths and unique qualities?

If your child has experienced any painful experiences (e.g., significant losses, traumas), please describe:

COVID-19 has had a dramatic impact on the lives of everyone, and it led to big changes in the lives of children and families. While there are some similarities across families, everyone’s experience has been unique. Please describe any notable changes your child experienced (either positive or negative) during the COVID pandemic, in any of the following areas: health, education, family, social.

Is there any other information that you think may help us in working with your child?

Who referred you to us?

6 Palmer Avenue | Scarsdale, NY 10583 | 914-723-2228