Child Intake Form - LINDA MESING COOK, LMHC

Todays Date

Child’s Name

Child’s Date of Birth:

Child’s Age:

Child’s Birth Gender:

Self-Reported Gender:

Mother’s Name:

Mother's Address

Street Address Address Line 2 City State ZIP Code

Father’s Name:

Father's Address

Street Address Address Line 2 City State ZIP Code

Mother Home Phone:

OK to leave message?

Mother Work Phone:

OK to leave message?

Mother Cell Phone:

OK to leave message?

Father Home Phone:

OK to leave message?

Father Work Phone:

OK to leave message?

Father Cell Phone:

OK to leave message?

Mother Email Address:

Father Email Address:

Relational Information:

Parents are:

Child’s Primary Parent is:

Time sharing schedule with non-residential parent:

Step-Parent Name:

Step-Parent Phone:

Step-Parent Name:

Step-Parent Phone:

Has this child been adopted?

Age at time of adoption:

Does your child have contact with their biological family, if adopted?

Emergency Contact:

Phone

Please list all persons living in the home with this child:

Name

Relationship

Nature of Relationship

Name

Relationship

Nature of Relationship

Name

Relationship

Nature of Relationship

Name

Relationship

Nature of Relationship

Name

Relationship

Nature of Relationship

Developmental Information:

Please explain any complications

Prenatal Illnesses and healthcare:

Was this child premature:

Weight & Height at birth:

Was this child breast fed?

if so, for how long?

Milestones:

Child sat without support:

Begin to crawl:

Walk without help:

Stay dry all night:

Stay dry all day:

Didn’t soil pants:

Ate with fork:

Dressed self completely:

Said first word:

Said first sentence:

Child’s Health History

List all childhood illnesses, hospitalizations, surgeries, allergies, head trauma, major accidents or injuries, or other medical illnesses:

Current Medications:

Has this child received any counseling, psychological, or psychiatric treatment in the past?

Please explain:

Child’s Pediatrician:

Phone

Would you like me to contact your child’s doctor to aid in their treatment?

Do you know or suspect that your child has used drugs or alcohol?

Please explain:

Educational Information

Name of child’s school:

Grade:

Child’s grades are:

Has this child ever been suspended?

Reason for suspension:

Has this child ever been retained?

If so, what grade?

Has this child participated in special classes such as gifted, learning disabilities, emotionally handicapped?

Please elaborate:

Would you like for me to consult with your child’s teacher?

Name of child’s teacher:

Phone

Social

How does your child interact with other children his/her age? (Please describe)

Leisure

List your child’s interests, hobbies, sports, or recreational activities:

Family History

Has there been any family history of mental illness, substance abuse, or legal problems for anyone in this family?

(Please explain)

Abuse

Do you know or suspect that your child has ever been physically, emotionally, or sexually abused, neglected, or bullied?

(Please explain)

Primary Cultural Background with which your child identifies:

Other

Please describe your primary concerns regarding your child at this time:

Referral: We are always grateful for referrals. May I thank the professional who referred you here?

(Their name/contact information):

Insurance Information: Name of Healthcare Insurance Company

Name of Insured Policy Holder:

Member Identification Number:

Please understand that utilizing health insurance benefits requires this provider to submit personal health information to your insurance company, specifically a procedural code indicating the type of treatment and length of time of the appointment. Additional information supplied to the insurance company is a diagnostic code for the purpose of reimbursement for services. Information obtained during the clinical process will not be released without your written consent unless court-ordered. Confidentiality may also be waived in situations where a client is in danger to self or others, or there are indications of child or elder abuse/neglect.

Terms of Service: I understand that it is customary to pay for services when rendered. I accept full responsibility for payment of any balance incurred for services. I further understand that without a 24-hour notice of intention to cancel, I will be charged the full administrative fee for services. Your therapist is available after regular business hours and on weekends by phone. However, an immediate response to your call cannot be guaranteed. Phone consultation after hours in excess of 10 minutes will be billed in accordance with your regular hourly fee. Please understand that in case of emergency, you may need to contact 911 or a local mental health facility or hospital.

I understand that my participation is purely voluntary and that I may withdraw whenever I wish. All records are the property of Linda Mesing Cook, M..S., LMHC.

I have read and understand all of the information on this form. I give consent for treatment of myself or the client indicated below. I understand that I may discuss with my therapist all aspects of my treatment and any issues on this form.

Client printed name:

Client Signature:

Date

Phone

This field is for validation purposes and should be left unchanged.