COUNSELING INTAKE QUESTIONNAIRE
(This form is intended to be completed by the child’s parents or primary caregiver)
Child's First Name
*
Child's Last Name
*
DOB
*
-
Month
-
Day
Year
Date
PROBLEM SEEKING SERVICE FOR:
If separated or divorced, how old was the child when the separation occurred?
What is the custody arrangement?
If any brothers or sisters are living outside the home, please list their names and ages:
PRESENTING PROBLEMS
Please list the questions you have and/or briefly describe the current difficulties for which youare seeking help:
0/200
How long has this problem been a concern?
What age was the child when the problem was first noticed?
What seems to help the problem?
What seems to make the problem worse?
Has the child received evaluation or treatment for the current problem or similar problem?
Yes
No
If yes, when and with whom?
SOCIAL AND BEHAVIORAL CHECKLIST
Place a check next to any behavior or problem that your child currently exhibits:
Prefers to be alone
Has difficulty with change/transitioning
Does not get along well with brothers and sisters
Is aggressive
Is shy or timid
Is more interested in things (objects than in people)
Engages in behavior that could be dangerous to self or others (describe)
Has special fears
Has trouble making eye contact
Bites nails
Sucks thumb
Wets bed
Lies
Steals
Hoards
Special skills
Uncertain of new situations
Difficulty with peer relationships
Fearful
Avoidance/fear related to school/community birthday parties
Overly cautious
Has frequent tantrums
Has frequent nightmares
Has trouble sleeping
Rocks back and forth
Walks on toes
Bangs head
Problems with eating
Is stubborn
Is much too active
Has staring spells
Is impulsive
Is slow to learn
Gives up easily
Has toileting problems
Routines, compulsions, obsessions
Other
Engages in behavior that could be dangerous to self or others (describe)
Has special fears (describe)
Special skills (describe)
Avoidance/fear related to...
school/community
birthday parties
Has toileting problems (describe)
Routines, compulsions, obsessions (describe)
Is there any other information that you think would help me work with your child or your family?
0/80
FAMILY MEDICAL AND MENTAL HEALTH HISTORY
Fill in any illness or condition that any member of the family has had. When you check an item, please note the family member’s relationship to the child.
Please list type of substance:
Relationship to the Child (Substance use):
Relationship to the Child (Cancer):
Relationship to the Child (Diabetes):
Relationship to the Child (Heart trouble):
Relationship to the Child (Epilepsy):
Relationship to the Child (Intellectual disability/delays):
Relationship to the Child (School difficulties):
Relationship to the Child (Language difficulties):
Relationship to the Child (Hearing Impairment):
Relationship to the Child (Down Syndrome):
Relationship to the Child (ADHD):
Relationship to the Child (Autism Spectrum Disorder):
Relationship to the Child (Anxiety Disorder):
Relationship to the Child (OCD):
Relationship to the Child (Depression):
Relationship to the Child (Bipolar Disorder):
Relationship to the Child (PTSD/Trauma History):
Relationship to the Child (Schizophrenia):
Relationship to the Child (Personality DIsorder):
Other:
Relationship to the Child (Other):
BEHAVIORAL AND OTHER INFORMATION
What are your child’s strengths?
What are your child’s favorite activities?
What are your child’s least favorite activities?
Has your child ever been in trouble with the law?
Yes
No
If yes, please describe briefly:
What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check mark next to each technique that you use:
Ignoring problem behavior
Scold child
Spank child
Threaten child
Reason with child
Redirect child’s interest
Tell child to sit on chair
Send child to his or her room
Take away some kind of activity
Other
How well does your child do the following? (Select yes/no)
Rows
Yes
No
Wake up during the night:
Difficulty falling asleep:
Does your child have a difficult time to wake up in the morning:
Sleep in own bed:
Take naps during the day:
Picky eater:
Avoid certain textures:
Gags at/on foods or utensils:
Avoids food that requires lots of chew:
Independent with toileting:
Following toilet training routine:
Difficulty playing alone:
Difficulty with pretend play:
Difficulty using playground equipment:
Avoidance of certain types of toys (i.e. textured toys):
Avoidance of any messy play (i.e. sand, paint, glue, etc):
Difficulty playing with other children:
Explain if needed.
Describe your child’s bedtime routine:
Explain eating:
Explain toileting:
Duration of play:
1-2 min
5-10 min
more
Describe your child’s peer skills/interactions: (Items to consider – making and keeping friends, social skills, ability to play with others, meeting new people, etc.)
Does your child exhibit tantrums:
Yes
No
Does your child exhibit mood outbursts (outbursts are longer than tantrums):
Yes
No
Have you observed any triggers to these behaviors? If so, please describe:
What strategies do you use to calm your child during a tantrum?
Preview PDF
Submit
Should be Empty: