Pediatric/Adolescent Intake Screening Form

Pediatric / adolescent intake
screening form

Pediatric/Adolescent Screening Form

All information on this form is strictly confidential; Please note this form is not used as a diagnostic tool. This form is to aid in determining appropriate services. A more comprehensive intake/evaluation will be administered once you are established as a client.

Child/Adolescent’s Name: *

Preferred Name *

Date *

Client Contacts

Mother's Name *

Age *

Father's Name *

Age *

Parent/Guardian Marital Status *

Single

Married

Widowed

Divorced

Separated

Relation to Child *

Biological

Adopted

Foster

Legal guardian

Mother's Address

City

State/Province

Zip/Postal

Country

Mother's Occupation *

Mother's Phone Number *

Best Time to Call *

A.M.

Mid-day

P.M.

Is it ok to leave a voicemail at this number? *

Yes

Father's Address

City

State/Province

Zip/Postal

Country

Father's Occupation *

Father's Phone Number *

Best Time to Call *

A.M.

Mid-day

P.M.

Is it ok to leave a voicemail at this number? *

Yes

Who has legal custody?

Type:

Who has physical custody?

Type:

Date of Patient's Birth *

Age *

Sex

Gender Identity

Sexual Orientation

Ethnicity

Hispanic or Latino or Spanish Origin

Not Hispanic or Latino or Spanish Origin

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Preferred Language *

Patient's Grade in School *

Current School *

Religion

Spiritual, Energy or Scientific Beliefs

Neurological Testing *

Yes

Date of Testing *

Completed By *

IEP/504 *

Yes

Date of Testing *

Educational Modifications

Pediatrician *

Phone *

Are you willing to give permission for provider collaboration? *

Yes

Current Therapist/Counselor/Provider: *

Phone *

Are you willing to give permission for provider collaboration? *

Yes

How Did You Hear About Us? *

What brings you to seek mental health treatment or consultation for your child/adolescent? *

Current Medication

Please list any CURRENT medications your child/adolescent are taking (please include over the counter medications, herbals and any nutritional supplements)

Medication

Date Started/Stopped

Dosage

Response/Side Effects

Provider/Facility

Add Remove

Symptoms

Please indicate what symptoms below your child has been experiencing over the past few weeks.

Emotional Concerns

Feels sad/unhappy

Irritable/angry

Feels hopeless

Down on him/herself

How difficult has feeling sad/unhappy made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has feeling irritable/angry made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has feeling hopeless made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has feeling down on him/herself made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Worries a lot

Feels he/she is bad

Does not show feelings

Seems to be having less fun

How difficult has worrying a lot made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has feeling he/she is bad made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has not showing feelings made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has having less fun made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Not enjoying life

How difficult has not enjoying life made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Physical Concerns

Complains of aches/pains

Tires easily/low energy

Acts if driven by a motor

Trouble sleeping

How difficult has aches/pains made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has tiring easily/low energy made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has being driven by a motor made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has trouble sleeping made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Frequent visit to doctor/RN

Excessive energy

Wants to be w/ you more

Gets hurt frequently

How difficult has frequent visits to the doctor/RN made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has excessive energy made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has wanting to be w/ you more made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has getting hurt frequently made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Restricting meals

Frequent tummy aches

Craves sugar

Constipation

How difficult has restricting meals made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has frequent tummy aches made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has sugar cravings made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has constipation made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Skin concerns

How difficult has skin concerns made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Diarrhea

How difficult has diarrhea made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Behavioral Concerns

Spends more time alone

Fidgety/unable to sit still

Has trouble w/ a teacher

Afraid of new situations

How difficult has spending more time alone made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has being fidgety/unable to sit still made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has trouble w/ a teacher made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has being afraid of new situations made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Less interest in friends

Fights w/ others

Absent from school

Cutting/self-harm

How difficult has less interest in friends made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has fighting with others made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has absence from school made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has cutting/self-harm made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Takes unnecessary risks

Acts younger than age

Does not listen to rules

Teases others

How difficult has taking unnecessary risks made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has acting younger than their age made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has not listening to rules made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has teasing others made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Blames others

Refuses to share

Takes things that don't belong to him/her

How difficult has blaming others made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has refusing to share made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has taking things that don't belong to him/her made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Cognitive Concerns

Distracted easily

Less interested in school

Excessive daydreaming

Trouble concentrating

How difficult has getting distracted easily made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has being less interested in school made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has excessive daydreaming made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has trouble concentrating made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

School grades dropping

Paranoia

Hallucinations

How difficult has school grades dropping made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has paranoia made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

How difficult has hallucinations made it for your child to function in school, get along/make friends, get along with family members or engage in leisure activities?

Not Difficult at All --> Extremely Difficult

Psychiatric History

Please list any prior counseling/mental health treatment/medication management:

Dates

Provider

Reason

Add Remove

Has your child/adolescent ever received inpatient psychiatric treatment? *

Yes

Dates

Facility

Reason

Has your child/adolescent ever attended an Intensive Outpatient Program? *

Yes

Dates

Facility

Reason

Please list all PAST psychiatric medication

Medication

Date Started/Stopped

Dosage

Response/Side Effects

Provider/Facility

Add Remove

Additional Assessment

Please check appropriate boxes

Has your child ever attempted suicide? *

Yes

Recently (1-3 months)

Today

Has your child ever engaged in self-harming behaviors? *

Yes

Recently (1-3 months)

Today

Has your child ever slapped, kicked, punched someone with intent to harm? *

Yes

Recently (1-3 months)

Today

Has your child ever hurt someone or destroyed property on purpose? *

Yes

Recently (1-3 months)

Today

Has your child ever been suspended from school for violent behaviors? *

Yes

Recently (1-3 months)

Today

Medical History

Most recent

Height *

Weight *

lbs.

Blood Pressure

EKG

Any abnormalities?

Yes

Physical

Labs

Any abnormalities?

Yes

Does your child have a history of STREP infections? *

Yes

Is your child, to your knowledge, sexually active? *

Yes

If Female: Is your child on any form of birth control?

Yes

List All Medical Conditions *

List Any Allergies to Medications/Foods *

Alcohol/Substance Use

To your knowledge, does your child

Drink alcohol? *

Yes

Use ANY illegal substance/medication not prescribed? *

Yes

Smoke or chew tobacco regularly? (Including vaping) *

Yes

Habits

Does your child drink caffeinated beverages? (coffee, tea, sodas)? *

How often? *

Any additional habits you are concerned about? *

Does your child exercise/involved in sports? *

Yes

Is your child involved in any extracurricular activities? *

Yes

Goals for Treatment

What are your goals for your child’s treatment? In other words, what things would you like to see change or be different about your child?

If you are human, leave this field blank.