CHILD/ADOLESCENT INTAKE FORM

Paul W. Case, Psy.D., LLC

Licensed Psychologist

109 West Park Drive, Suite 225

Brentwood, TN 37027

(615) 669-8765 | drpaul@drpaulcase.com

CHILD/ADOLESCENT INTAKE FORM

Please provide the following information and answer the questions below. Information that you provide here is protected as confidential.

Basic Information

Child/Adolescent Name *

First Name Last Name

Birthday *

Date

Parent/Guardian(s) Name *

Prefix First Name Last Name

Parent/Guardian(s) Name

Prefix First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

Do you give this office permission to text your cell?

Please note: Email and texting are not considered a confidential medium for communication.

Do you give this office permission to email you?

Please note: Email and texting are not considered a confidential medium for communication.

E-mail

example@example.com

Emergency Contact

Name

Phone

Relation

How did you hear about Dr. Case?

Please describe what is bringing you in today?

Below is a list of common complaints. Please check any that your child has been experiencing in the last few weeks:

Yes

No

Mood swings

Frequent crying episodes

Nervousness

Hopelessness/Helplessness

Lack of energy

Appetite changes

Nightmares or night terrors

Fidgety

Weight gain or loss

Defiance

Hallucinations

Excessive worry

Obsessive Rituals (i.e. hand washing, cleaning, or double checking things)

Obsessive thoughts

Compulsive behaviors

Suicidal thoughts/attempts

Self-harm

Aggression to others

Sleeping too much

Not sleeping enough

Feel panicky or terrified

Body image issues

Isolation/social withdrawal from family & friends

Feel life is not worth living

Temper outbursts

Easily annoyed or irritated

Low energy

Upset stomach or nausea

Body aches and pains

Loneliness

Perfectionist

Self-consciousness

Self doubt

Low self-esteem

Trouble concentrating

Faintness or dizziness

Feel worthless

Argumentative

Dislike crowds

Feeling over-sensitive

Memory loss

Feel inferior to others

Difficulty making decisions

Stress or tension

Afraid to go out in public

Avoid certain things

Frightening/ disturbing thoughts

Alcohol or drug use

Prescription drug abuse

Anger management

Blackouts

Excessive behaviors (spending, gambling, etc)

Depression/sadness

Racing thoughts

Frequent headaches

Has your child previously received any type of mental health services (psychotherapy, psychiatric services, etc.)?

If Yes, please provide the name and contact info of previous therapist/practitioner:

Is your child currently under the care of a Medical Doctor?

If Yes, please provide the name and contact info of medical doctor:

If Yes, please list all current medications:

Family Dynamics

Parent(s)/Guardian marital status?

Single Married Divorced Separated Widowed

Who does the child/adolescent live with currently?

Who lives in the household with the child/adolescent? (List all individuals)

List all stepparents and indicate whether they are stepmothers and/or stepfathers. Briefly describe your child’s relationship with them:

Please describe the relationship between the parent(s)/guardian(s) and the child/adolescent:

List all siblings and ages. Briefly describe your child’s relationship with them:

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in the space provided for example (mother, father, brother, paternal mother etc.):

Yes

No

List Family Member

Alcohol/Substance Abuse

Anxiety

Depression

Domestic Violence

Eating Disorder

Obesity

Obsessive Compulsive Behavior

Bi-polar Disorder

Schizophrenia

Suicide Attempts

Self-Harm Behavior

Trauma

What do you consider to be some of your child’s strengths?

What do you consider to be some of your child’s weaknesses?

Anything else you think I should know?