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Intake - Adolescent (ages 12 - 17)
Please complete this form prior to our first session. All information is protected by confidentiality.
** This is a Secure form. All information sent will be encrypted.
*
Indicates required field
Legal Name of Youth
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First
Last
Nick Name
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number of Parent
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Name of Parent of this phone #
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Can a message be left at this phone #?
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Yes
No
Email of Parent
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Birth date of Youth
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Youth lives with
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Both biological parents
One biological parent
Splits time between parents
Step parent and biological parent
Adoptive parents
Friend's parents
Current Age of Youth
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Youth's parents are
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Married
Separated
Divorced
Widowed
Never married
Parent #1 Name
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First
Last
Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Can a message be left at this phone #?
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Yes
No
This parent is
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Biological
Step parent
Adoptive parent
This parent is employed outside the home
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Yes
No
Parent #2 Name
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First
Last
Phone Number
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Can a message be left at this phone #?
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Yes
No
This parent is
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Biological
Step parent
Adoptive parent
This parent is employed outside the home
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Yes
No
Add'l Caregiver Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Relationship to Youth
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Does caregiver live with youth?
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Yes
No
Why are you seeking counseling for the youth?
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Has the youth already been in counseling?
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Yes
No
How has the family tried to resolve the youth's issues?
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If yes, please give the counselor's name and city located.
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Sibling Name
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Sibling Name
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Sibling Name
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Sibling Name
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Sibling Age
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Sibling Gender
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Male
Female
Sibling Age
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Sibling Gender
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Male
Female
Sibling Age
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Sibling Gender
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Male
Female
Sibling Age
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Sibling Gender
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Male
Female
Does this sibling live at home with youth?
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Yes
No
Does this sibling live at home with youth?
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Yes
No
Does this sibling live at home with youth?
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Yes
No
Does this sibling live at home with youth?
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Yes
No
Behaviors / Symptoms
Youth struggles with:
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Distractibility
Hyperactivity
Sadness/Depression
Sibling/Peer Conflict
Conflict with Parents
Fear Away From Home
.
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Anxiety/Worry
Panic Attacks
Hearing Voices
Visual Hallucinations
Withdrawal
Severe Mood Swings
.
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Defiance
Aggression/Fights
Irritability/Anger
Loneliness
Fatigue
Suspicion/Paranoia
.
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Running Away
Stealing
Curfew Violations
Suicidal Thoughts
Self-Harm Behaviors
Change in Eating
Check if Youth has Experienced
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Parent Illness
Parent Death
Parent Incarceration
.
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Neglect
Victim of Crime
Parent Substance Abuse
.
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Multiple Family Moves
Emotional Abuse
Sexual Abuse
.
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Physical Abuse
Violence in the Home
Teen Pregnancy
Does your youth use recreational drugs?
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No
Yes
I'm not sure
If yes, please explain
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Education
Name of current school with city.
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Current Grade
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Most current school year performance
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Very Good
Good
Average
Poor
Failing
Previous school year performance
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Very Good
Good
Average
Poor
Failing
Most current school year behavior
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Very Good
Good
Average
Poor
Previous school year behavior
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Very Good
Good
Average
Poor
Medical
Check any Medical Condition
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Diabetes - Type 1
Diabetes - Type 2
Asthma
.
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Allergies
Headaches
Seizures
.
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Stomach Aches
Sleep Disorder
Hearing Issues
.
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Speech Issues
Vision Issues
Serious Surgery
List any additional Medical Conditions not covered above.
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Name of Medication
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Name of Medication
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Name of Medication
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Name of Medication
*
Name of Medication
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Dose
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Dose
*
Dose
*
Dose
*
Dose
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Reason for Taking
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Reason for Taking
*
Reason for Taking
*
Reason for Taking
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Reason for Taking
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Primary Physician
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Psychiatrist
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Other Medical Specialist
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Phone Number
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Phone Number
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Phone Number
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Social / Cultural
Check who the Youth has for social support
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Neighborhood Friends
School Friends
Family
.
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Faith Based Friends
Community Group/Park & Rec
Lacks Good Social Support
Which Cultural / Ethic group does your youth belong?
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Has the youth experienced any problems due to his/her cultural/ethnic group? Please describe
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Legal
If parents Separated/Divorced what are the custody arrangements?
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Do the Parents have Joint Custody?
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Yes
No
Doesn't apply
Has the Youth ever been arrested
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No
Yes
If yes, what were the charges?
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Please share any information you feel would be helpful to me, that hasn't been covered above.
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Which Insurance Company will you be using?
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CalOptima
Cigna
TriCare
Other*
Not using insurance
*If Other, please list which Insurance Company you have
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Insurance Member Number - it's important to include this as your coverage needs to be confirmed.
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Thank you for taking the time to complete this form. Your responses will help me better serve your youth.
~
Liz Birch, LMFT
Submit
Home
About Me
Talk Therapy
Hypnotherapy
Fees, Insurance, Directions
Why Do You Want Therapy?
Blog
Important Forms
Podcasts
Confidentiality