Amber Monroe, MFT 49337

Licensed Marriage and Family Therapist

8355 La Mesa Blvd.
La Mesa CA, 91942

619-382-5154

TEEN/CHILD INTAKE FORM

Please note: information provided on this form is protected as confidential information.

Name: Date:

Referred By (if any):

DOB: Age: Gender:

Mother’s Name: Father’s Name

Primary Address: ­­

Secondary Address: □N/A

Home Phone:­­­ (M) (F) May we leave a message? □ Yes □ No

Cell/Work/Other Phone: (M) (F) May we leave a message? □ Yes □ No

Email: (M) (F) May we leave a message? □ Yes □ No

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Clinician Notes:

Employment Status: □ Working Part Time □ Looking for a job □ Not working

Clinician Notes:

School Name: Grade: Counselor:

Clinician Notes:

Religion/Spirituality? □ N/A

Mental Health Treatment History

Have you previously received any type of mental health services (psychotherapy, psychiatric services, etc.)? □ No □Yes

If yes please check all that apply: □ Outpatient □ Group Suport □ IOP □ PHP □ Residential □ Inpatient

Clinician Notes:

Are you currently taking any prescription medication? □ Yes □ No If yes, please list:

Have you ever taken psychiatric medication in the past ? □ Yes □ No If yes, please list with approximate dates:

Mental Health Information

Current Symptoms: □ Depression □ Mania □ Anxiety □ Agitation □ Anger □ Panic □ OCD □ Low Libido

□ Low Self Esteem □ Poor Hygiene □ Ruminating Thoughts □ Isolation □ Eating Disorder □ Substance Use □ Social Phobia □ Other Phobia □ Hallucinations □ Paranoia □ Perfectionism □ Chronic Physical Pain

Clinician Notes:

Current Stressors: □ School friends □ School work □ Relationship □ Parents □ Family □ Money □ Other Friends

Clinician Notes:

Current Self Harm Behaviors: □ Cutting □ Hair Pulling □ Skin Picking □ Pinching □ Punching □ Burning □ Slapping

Do you have a history of self harming? □ Yes □ No

Clinician Notes:

Current Safety Status: □ Thoughts of ending my life □ Plans to end my life □ Intent to end my life □ Thoughts of hurting others □ Plans to hurt others □ Intent to hurt others

Do you have a history of wanting to or attempting to end your life or harm others? □ Yes □ No

Clinician Notes:

Trauma History: □ Physical □ Sexual □ Emotional/Mental □ Verbal □ Assault □ Witnessed DV □ Bullying

Clinician Notes:

Substance Abuse History and Current use

Do you drink alcohol more than once a week? □ No □ Yes □ History of only

Clinician Notes:

How often do you engage in recreational drug use? □ Daily □ Weekly □ Monthly □ History of only

Clinician Notes:

General Health Information

How would you rate your current physical health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good

Clinician Notes:

How would you rate your current sleeping health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good

Clinician Notes:

How would you rate your current exercise health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good

Clinician Notes:

How would you rate your current nutritional health? □ Poor □ Unsatisfactory □ Satisfactory □ Good Very □ Good

Clinician Notes:

Additional Information

Who lives in your current home?

Who lives in your other home? □ N/A

Who are you closest to in your family?

What type of consequences are applied in your household?

Does anyone in your immediate family struggle with drug abuse, alcohol abuse or an eating disorder?

Does anyone in your immediate family struggle with any psychiatric symptoms?

Who are your social supports? i.e. friends/boyfriend/girlfriend/parents/grandparents etc.?

What do you like to do for fun?

What do you consider your strengths & weaknesses to be?

Who are your friends?

Do you like school?

What significant life changes or stressful events have you experienced recently?

What is most difficult for others to understand about you?

What has been the happiest experience of your life?

What has been the saddest experience of your life?

How will your parents, friends and classmates know that you are doing better?

If you could, what would you change about your family?

Relationship Status: □ I have a boy/girlfriend □ I want a boy/girlfriend □ I am too young for a boy/girlfriend

Have you ever been sexually active? □ Yes □ No Are you currently sexually active? □ Yes □ No