ADOLESCENT INTAKE & DEVELOPMENTAL HISTORY
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Name of Adolescent
First Name
Last Name
Address
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Date of Birth
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School and Grade
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Name of Pediatrician
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Who Referred You?
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PARENT/GUARDIAN NAME
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First Name
Last Name
Relationship to Minor
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Home Address
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Occupation
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Cell Phone
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(###)
###
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Email
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PARENT/GUARDIAN NAME
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First Name
Last Name
Occupation
Phone
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(###)
###
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Email
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PARENTS' MARITAL STATUS
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If not married, date of divorce:
MM
DD
YYYY
Are there other relatives or adults that are important caretakers for your team (i.e., stepparent, significant other, grandparent, nanny)? If so, please list with name and relationship to minor.
Please list the minor's siblings if any including step-siblings. Please list each name and their relationship to the minor.
If the child was adopted, indicate their age at the time of adoption and their country of birth.
DEVELOPMENT, PREGNANCY & DELIVERY
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Any illnesses during newborn period?
Were there:
Any other complications during the first year?
spoke in simple sentences:
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MEDICAL HISTORY
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Any illness other than normal childhood diseases?
Check any of the following that the child experienced:
Checkbox
List any surgeries or hospitalizations. If none, so indicate.
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List any medications stating for each the reason for the medication and the dosage. If none, so indicate.
Check any of the following that the minor exhbits:
Describe any of those checked above in more detail
SCHOOL HISTORY
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Rate your child's school experience related to ACADEMIC LEARNING (select one response for each)
Nursery School
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Elementary School
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Middle School
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Current Grade
Has your teen even had to repeat a grade? If so, when?
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Present class placement:
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Please specify any special or resources classes or services (if any):
Please rate your child's experience related to BEHAVIOR for each of the following:
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Nursery School
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Elementary School
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Middle School
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Current Grate
Does your teen's teacher describe any of the following?
Briefly describe any other classroom behavioral problems:
FAMILY
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How does your child get along with each parent?
Is this child closer to one parent than the other?
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Has this child ever experienced any parental separations, divorces, or death?
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Yes
No
If yes, when? Please describe the circumstances.
How old was the teen at that time?
How often does your teen see each parent and what is the schedule?
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FAMILY HISTORY
Describe any psychiatric problems, drug abuse, or alcoholism in immediate and extended family:
Have either parents or any of the blood relatives had a problem like your teen is experiencing?
Yes
No
If yes, please describe:
Does your teen socialize with same-aged peers?
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What role does your teen usually take in peer group games or activities (e.g., bossy, leader, aggressive, passive, etc.)?
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What are your teen's strengths and areas of greatest accomplishments?
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MAJOR AREAS OF CONCERN
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What is your teen's major area of concern and when did it begin?
How have you tried to resolve the problem?
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What have you found to be effective?
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Has your teen been treated for this problem before?
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If so, by whom?
What were the results?
Has your teen had any psychological testing in school or privately conducted?
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ADDITIONAL REMARKS:
Please use this section to write any additional comments you wish to make regarding your teen's difficulties.
