Child Intake Form - Linda Kastner, LPC

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465 Date: __________________________________________________

Child/Adolescent Intake Form Client Name:___________________________________________________________________________DOB_______________________AGE:____________________ Address: ______________________________________________________________________________________________________________________________________ Street

City

Zip Code

Name of Person completing form: _______________________________________________________________________________________________________ Relationship to child: ___________________________________________________ With whom does the child reside: (circle)

Biological Parents Adoptive Parents Foster Parents DHS Home Other: ____________________________________________________________________

Parent Information: Mother’s Name: __________________________________________________________________________________________________ Age: _____________ Address: __________________________________________________________________________________________________ Phone: ___________________________ Father’s Name: ___________________________________________________________________________________________________ Age: ______________ Address: _________________________________________________________________________________________________ Phone: ____________________________ Marital Status of Biological/adoptive parents: (circle) Married

Married

Divorced

Separated

Widowed

Never

If separated/divorced, who has legal custody:_______________________________________*Please Provide Legal Documentation Date of separation/divorce: ___________________________ If a parent is deceased, what was the date of death: _________________________ If Parents are remarried: Date of remarriage: _______________________________ Stepmother’s Name: ________________________________________________________________________________________________________________________ Stepfather’s Name: __________________________________________________________________________________________________________________________ Presenting Problem: Please describe the problem that has brought you here today: _______________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________

Client Name:

Date:

1

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465

Please check any symptom/problems your child/adolescent has been experiencing: ☐ Having suicidal thoughts ☐ Breaks laws/rules ☐ Has a plan to kill self ☐ Panic Attacks ☐ Low mood ☐ Afraid/unable to leave home/parent ☐ Difficulty falling/staying asleep ☐ Extreme unreasonable fears ☐ Excessive sleeping ☐ Intense fear of social situations ☐ Change in appetite-decreased or increased ☐ Trouble by repetitive thoughts or behaviors ☐ Difficulty concentrating ☐ Intrusive, upsetting memories of past events ☐ Lost interest in previously enjoyed activities ☐ Using alcohol or other illegal substance ☐ Decreased energy ☐ Sexually active (_______Straight_________Gay________Bi) ☐ Tense or more irritable than usual ☐ Gender identification ☐ Excessive worry ☐ Problems within the family ☐ Argumentative ☐ Problems with Friends ☐ Aggressive behavior/communication ☐ Educational/school problems ☐ Destructive or violent thoughts or behavior ☐ Problems at work ☐ Attempts to hurt, harm, or mutilate self ☐ Housing problems ☐ Anger outbursts ☐ Financial/economic problems in the family ☐ Disobedient ☐ Problems with the legal system ☐ Cruel to animals ☐ Careless, high-risk behavior ☐ Fire setting ☐ Highly elevated mood/excessive energy ☐ Runaway ☐ Hyperactivity/Inattention Other symptoms you’ve observed: _________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Has your child/adolescent ever attempted to take his/her own life? No

Yes

Has your child/adolescent ever purposely cut or burned her/himself? No Yes

If yes, when? _________________________________ If yes, when? _________________________________

Please describe when the current problems began and how they affect your child/adolescent’s functioning at home, school, with friends and in other areas of life: _____________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ What are your goals/expectations for treatment:_________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________

Client Name:

Date:

2

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465

PAST MENTAL HEALTH TREATMENT Has your child/adolescent ever received outpatient mental health treatment/counseling before:

YES

NO

If Yes, why, when and where: ______________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ Has your child/adolescent ever been hospitalized for mental health/behavioral reasons?

YES

NO

If yes, please describe why, when, and where: ____________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Please list any mental health diagnoses your child/adolescent has been given:________________________________________________________ _________________________________________________________________________________________________________________________________________________ Medications: Please list all medications your child/adolescent is currently taking: Medication

Dosage

Purpose

To your knowledge, has your child/adolescent ever used illegal drugs or abused prescription drugs?

YES

NO

If yes, please describe: _______________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Does your child/adolescent:

Smoke

Smokeless Tobacco

If you have circled one of the above, is this behavior

Client Name:

current

Drink Alcohol

Drink Beer

NONE

past

Date:

3

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465 HEALTH INFORMATION How would you describe your child’s overall health? (circle) Does your child/adolescent have chronic medical problems?

GOOD Yes

FAIR

POOR

No

If Yes, please describe: _______________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Has your child/adolescent ever experienced a head injury, loss of consciousness, or seizure?

Yes

No

If Yes, please describe: ______________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Does the child/adolescent have a history of any serious injuries or medical problems?

Yes

No

If Yes, please describe: ______________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Please list any problems experienced by the mother during her pregnancy, labor, or delivery with this child: _____________________ _________________________________________________________________________________________________________________________________________________ Did the mother smoke, drink, or use any illicit or harmful drugs during this pregnancy?

Yes

No

If Yes, please explain: ________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ FAMILY INFORMATION Is this child/adolescent your biological child?

Yes

If No, what age was he/she adopted or came to live with you? Is there contact with both biological parents?

Yes

No ________________ No

Please explain: ____________________________________

_________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Is there conflict in the home, such as problems in parents marriage or problems with parenting?

Yes

No

Please explain: ______________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________

Client Name:

Date:

4

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465 *Are you involved in any litigation, such as custody or visitation changes related to your child?

Yes

No

_________________________________________________________________________________________________________________________________________________ *I will not get involved in a custody/visitation issue with children/adolescents that I am seeing for counseling. Who lives in this child/adolescent’s home: Name

Age

Relationship to child

Quality of Relationship

1 2 3 4 5 6 If your child/adolescent spends time at another parents home, please list household members of that home: Name

Age

Relationship to child

Quality of Relationship

1 2 3 4 5 6 Does this child/adolescent have grandparents that are significant in their lives?

Yes

No

Name

Paternal

Maternal

Name

Paternal

Maternal

Name

Paternal

Maternal

Name

Paternal

Maternal

Client Name:

Date:

If yes:

5

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465 Family Mental Health History Please check any mental health issues that your child/adolescent’s family member (include parents, siblings, grandparents, aunts, uncles, cousins) have/had. _________Depression __________Anxiety _____________ADHD ___________BiPolar _________Schizophrenia __________Alcohol/Drug Problems _____________Learning Disability ___________Panic Disorder _________Autism Spectrum __________Mental Retardation _____________”Nervous Breakdown” ___________PTSD _________Suicide or attempted __________ OCD (Obsessive/Compulsive Disorder) SOCIAL ISSUES Does your child/adolescent have quality relationships with other children? Does your child/adolescent tend to spend more time with

Yes

OLDER

YOUNGER

No SAME AGE

children?

Do you have concerns about your child’s/adolescent’s friends? Yes No If yes, explain: ________________________________________________________________________________________________________________________________ EDUCATION Where does your child attend school? _____________________________________________________________________________________________________ If homeschooled, who does the instruction: _______________________________________________________________________________________________ What grade level is he/she in? _______________________ What are his/her typical grades? _____________________________________________ Has your child ever been held back?

YES

NO

What are his/her academic strengths? ______________________________________weaknesses?_______________________________________________ Has there been a change in his/her academic performance?

YES

NO

If YES please explain: ________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Has your child ever received Academic or IQ testing?

YES

NO

If yes, who did the testing and what were the results: ____________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ (A copy of this report for his/her file would be helpful) Does your child have an I.E.P.?

YES

Is your child in Accelerated or Honors programs?

NO YES

If yes, describe: _____________________________________________________ NO

Has your child/adolescent had problems with any of the following: YES NO Truancy, explain: ______________________________________________________________________________________ YES NO Fighting, explain: ______________________________________________________________________________________ YES NO Absenteeism, explain: _________________________________________________________________________________ YES NO Detention, explain: ____________________________________________________________________________________

Client Name:

Date:

6

Linda Kastner, L.P.C. 9826 N.E. 23rd. St.  Midwest City, OK73141 Phone: (405) 769-4799  FAX: (405) 260-9465 YES YES

NO NO

Suspensions explain: _________________________________________________________________________________ School refusal, explain: _______________________________________________________________________________

INTERESTS AND ACTIVITIES What are your child’s/adolescent’s favorite activities: ___________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ Does your child/adolescent have any particular talents? ________________________________________________________________________________ What are the things you like most about your child/adolescent: ___________________________________________________________________ _________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________ ****************************************************************************************************************************** ______________________________________________________________________________________________ Signature of person completing this form

_________________________________________ Date

Office use only below this line ****************************************************************************************************************************** Notes:

Initial Diagnosis: Axis I: Axis II: Axis III: Axis IV: Axis V:

Client Name:

Date:

7