Student’s Name:

Date:

Grade:

Referred by:

Clinician Completing Intake:

Identifying Information

Date of Birth:

Age:

Gender:

Racial/Ethnic Identity:

Country of Origin:

If born outside of the U.S., at what age did you arrive?

Primary Language:

Other Languages spoken in the home:

Parent/Guardianship

☐ Mother and Father

☐ Only Mother

☐ Only Father

☐ Joint Guardianship

☐ Other

Adults living with student:

☐ Mother

☐ Father

☐ Stepmother

☐ Stepfather

☐ Grandparent(s)

☐ Other

Name of Parent/Guardian:

Relation to student:

How long have you lived with this Parent/Guardian?

Name of Parent/Guardian:

Relation to student:

How long have you lived with this Parent/Guardian?

Siblings (Names and Ages):

Briefly describe your relationship with your parent:

 Briefly describe your relationship with your other parent:

Presenting Problem

Why were you referred?

What issues are you struggling with at this moment?

How long have these issues been going on?

Mental Health History

Are you currently involved in counseling or have you been involved in counseling in the past?

☐ Yes ☐ Denies ☐ Unsure

If “yes”, please provide details:

Does anyone in your family have depression, anxiety, or other mental health issues?

☐ Yes ☐Denies ☐ Unsure

If “yes”, please provide details:

Have you ever been hospitalized for a psychiatric issue? ☐ Yes ☐ Denies ☐ Unsure

If “yes”, please provide details:

Grief and Loss History

Are your parents separated or divorced?

If “yes”, please provide details:

Has someone close to you died (includes friends, family, and pets)?

Have you experienced any other significant losses in your life? (ex. friendship, migratory loss, loss of home?)

Substance Abuse History

Is there a history of drug or alcohol use in your family or is anyone currently using drugs or alcohol?

☐ Yes ☐ Denies ☐ Unsure

If “yes”, please provide details:

Do you currently use alcohol or any other drug(s)?  ☐ Yes ☐ Denies

If “yes”, how often?

Trauma History

Have you ever been abused physically, emotionally, sexually, or verbally? ☐ Yes ☐ Denies

Has child protective services ever been involved with your family? ☐ Yes ☐ Denies

If “yes”, please provide details:

Have you ever experienced bullying? ☐ Yes ☐ Denies

If “yes”, please provide details:

Legal History

Have you ever been in trouble with the law? ☐ Yes ☐ Denies

If “yes”, please provide details:

Academic History

How are you currently doing in school? 

What impact has virtual learning had on you academically?

Is there any specific class you are struggling with? ☐ Yes ☐ Denies

If “yes”, please provide details:

Are you currently receiving any modifications in any of your classes? ☐ Yes ☐ Denies ☐ Unsure

Are you currently experiencing attendance issues (absences, lates, and/or cuts)? ☐ Yes ☐ Denies

If “yes”, please provide details:

Medical History

Do you have any current medical issues? ☐ Yes ☐ Denies

If “yes”, please provide details:

Have you ever been hospitalized for a medical issue? ☐ Yes ☐ Denies

If “yes”, please provide details:

Had surgery on eye as a child, no lingering issues.

Does anyone in your family have health problems ? ☐ Yes ☐ Denies

If “yes”, please provide details:

Sexual Health

Are you currently sexually active? ☐ Yes ☐ Denies

If “yes”, have you gone for your annual check up or STI (Sexuall Transmitted Infections) testing within the last year? ☐ Yes ☐ Denies

*Ask student if they have any questions about sexual health, birth control, etc. Refer to appropriate resources.*

Are you a parenting teen? ☐ Yes ☐ Denies

If “yes”, please provide name and age of child(ren):  

Other

Who do you consider to be your support system?

Who do you trust the most?

What do you like to do for fun?

How would you describe yourself?

FEELINGS/THOUGHTS/SYMPTOMS

(Check all that apply)

Feelings

       ☐ Helpless                     ☐ Anxious        

       ☐ Depressed                     ☐ Out of Control

       ☐ Shameful                     ☐ Afraid        

       ☐ Angry                     ☐ Numb        

       ☐ Guilty                    ☐ Relaxed        

       ☐ Hopeless                    ☐ Happy        

       ☐ Lonely                    ☐ Excited        

      ☐ Sad                                         ☐ Hopeful

      ☐ Stressed                        ☐ Moody

      ☐Unhappy                    

Emotional Symptoms/Behavior

        ☐ Procrastinating                       ☐ Crying

        ☐ Acting out Aggressively        ☐ Impulsivity

        ☐ Disorganization               ☐ Recklessness

        ☐ Conflicts with Parents           ☐ Nightmares

        ☐ Poor Concentration                ☐ Attempting Suicide 

        ☐ Goals/Ambition                       ☐ Injuring Self

       ☐  Irritability                                  ☐ Eating Less

        ☐ Happy with Friendships       ☐ Over Eating

        ☐ Staying alone                            ☐ Spiritual Problems       

       ☐ Worried about body image   ☐ Dating problems

Physical Symptoms

☐ Insomnia/Sleep Problems        

☐ Sleeping too much            

☐ Dry Mouth

☐ Tired                    

☐ Vomiting/ nausea

☐ Weight Gain/Loss  

☐ Pain        

☐ Headaches              

☐ Dizziness        

☐ Tightness in Chest

☐ Numbness/Tingling

☐ Rapid Heartbeat        

Thoughts

☐ Confused           ☐ Paranoid

☐Racing                ☐ Unlovable

☐Obsessive          ☐ Confident

☐ Distracted         ☐ Sensitive

☐ Unmotivated    ☐ Unattractive

☐ Suicidal             ☐ Homicidal