Youth Intake Questionnaire for Parents/Guardians

Child’s name

Child’s Age

Child’s Birthdate

Who referred you?

Referrer’s Address

Referrer’s Phone

Your Name

Relationship to Child

Your Phone

Family Physician/Pediatrician

Family Physician/Pediatrician Phone

What is happening in your child’s life that resulted in this appt?

When did the current problems start?

What were the stressors happening in the child’s life at the time?

Has your child ever been treated by Psychiatrist/Psychologist/counselor?

yes

no

If yes, provider’s name

Date

Reason for treatment

Child’s Parents

Name

Age

Currently living with child?

yes

no

Add Parent Remove Parent

Names and ages of others living in the home

Name

Age

Relationship

Add Person Remove Person

Cultural background

Religious background

Does the child have any significant health problems?

no

yes

If yes, when?

past

present

If yes please explain

Name of Physician monitoring this condition

Current Medications

Name

Dosage

Add Remove

Who prescribed these medications for your child?

Radio Buttons

Option 1

Option 2

Has the child ever been hospitalized? Surgeries? Serious injuries, broken bones, head injuries?

yes

no

If yes please explain

Sleep Pattern Issues

What time does your child go to bed?

How many hours of sleep does he/she get

Please check any of the following that you are concerned about regarding your child:

Does your child hear or see things that are not there?

no

yes

If yes, describe

Has your child been Physically/emotionally/sexually abused?

no

yes

If yes please explain

Has your child been involved with the legal/criminal system?

no

yes

If yes please explain

I certify all the above is true to the best of my knowledge (enter parent’s/guardian’s name as signature)

Date