Child Intake Form
In order for me to be able to fully evaluate your child and understand your referral questions, I request that you fill out the following intake form completely to the best of your ability. I realize that there is a lot of information, but every question is important. Please do the best you can to answer each an every question completely and accurately. Thank you!

*** This practice can not be held liable for information intercepted during the transmission of this form. If you are uncomfortable using this transmission method to complete your history forms, please contact the office for alternative methods of completion. This practice does not provide preferential treatment to patients based on the type of form they choose to complete. ***

Date *
MM
/
DD
/
YYYY
INFORMATION ABOUT YOUR CHILD *
Child's Name
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Sex *
Child's Grade *
Your answer
INFORMATION ABOUT YOU *
Your Name
Your answer
Your e-mail address *
Your answer
Your phone number *
Your answer
Relation to child *
Your answer
Your occupation, age, and highest grade level completed *
Your answer
Please describe why you are seeking an assessment for the child *
Your answer
Has the problem affected the child's academic or social performance? *
How much is the child's daily life impacted by this problem? *
Not at all
A great deal
How or by whom were you referred to Kelly Gin, Ph.D. for assessment? *
Your answer
Describe the child's greatest strengths *
Your answer
Describe the child's greatest weaknesses *
Your answer
List all people living in the child's home including name, age, and relation to child *
(i.e. natural parents, stepparents, foster, adopted, siblings, extended family)
Your answer
Please list the important events or changes that have occurred in your child’s lifetime (for example: deaths, marital separations, divorces, remarriages, family moves, loss of important friendships, serious illnesses, financial problems, parental conflict, family violence, etc.). List any other events which, in your opinion, have had important meaning or significant impact on your child or your family. If you are uncertain about the significance, please list it anyway. Please provide specific dates during which each event occurred and identify the persons involved. *
Your answer
PREGNANCY *
(check all that apply):
Required
Explain other:
Your answer
DELIVERY *
Were any of the following present during or soon after the delivery? (check all that apply)
Required
Explain other:
Your answer
How many weeks gestation (full term or premature)? How long was labor? How much did the baby weigh? *
Your answer
During the child's first year of life, was there anything (even if it had nothing to do with the baby) that caused unhappiness in the family, or placed the parents under strain? *
Your answer
MEDICAL HISTORY *
Has the child experienced any of the following (check all that apply)
Required
Explain other:
Your answer
How do you feel you child has devloped? *
Faster than average
Average
Slower than average
Physical and motor development
Talking and language development
Relationships and social development
Did the child have any problems in the following areas? *
No
Yes
Still unable
Learning shapes and colors
Learning to ride a bicylce
Learning to climb stairs
Learning to use zippers and buttons
Cutting with scissors
Learning to tell time
Learning to tie shoes
Separating form parents
Learning to read
Making friends
Understanding jokes
Telling left from right
Learning to count or add
Reciting the alphabet
Adjusting to change
Describe anything else the child had difficulty learning
Your answer
MEDICAL HISTORY *
List CURRENT medical problems
Your answer
Has the child been hospitalized for illness or accident? *
When, where, why, how long, outcome?
Your answer
Medications *
Please list all medications the child is currently taking, along with information regarding what disorder they are prescribed to treat, the dosage, how often, what time of day taken, and any side effects that have been noticed. Please include all over-the-counter, herbal, and “nontraditional” medicines. Attach a sheet if necessary.
Your answer
Has the child ever taken medication for ADHD that resulted in no improvement or worse behavior? Describe. *
Your answer
List any allergies (food, drug, environmental)
Your answer
Vision and Hearing *
Normal
Corrected
Needs to be checked
Vision
Hearing
Describe the child's sleeping habits and behavior: *
(bedtime, wake up time, difficulty falling/staying asleep, insomnia, nightmares, etc).
Your answer
Describe the child's eating habits. Any change or concerns with appetite? Is he/she unusually picky for his/her age? *
Your answer
Any family history (close relative) of: *
Yes
No
Don't Know
Anxiety
Depression
Manic Depression/Bipolar Disorder
ADHD/ADD
Autism
Learning Disability
Other
Explain any family history marked above:
Your answer
Psychiatric Diagnoses
List all diagnoses, dates given, and name/type of professional diagnosing
Your answer
Other psychiatric information
Has the child...
Yes
No
Don't Know
Been prescribed medication for a mental health problem?
been hospitalized for a mental health problem?
had counseling or therapy?
engaged in self-harm?
attempted suicide?
been a victim of physical abuse?
been the victim of sexual abuse?
been the victim of emotional abuse?
witnessed extreme violence?
Does the child use drugs or alcohol? Which and how often?
Your answer
Does the child use tobacco products? Which type and how often?
Your answer
SCHOOL HISTORY and INFORMATION *
In what grade and school/school district is the child enrolled?
Your answer
Did the child attend daycare? Between what ages? How did he/she react to the setting? *
Your answer
Did the child receive Early Intervention services (e.g., ECI, Head Start, PPCD)? *
If yes, when, how often, which services?
Your answer
How would current teachers describe your child? *
Your answer
Special educational services *
Yes, currently
In the past
Never
Don't know
Special education support
Speech/language therapy
Special education counseling
Occupational Therapy
Physical Therapy
Section 504 Services
Other Intervention Services
If the child receives or received Special Education services, which eligibility was met? *
check all that apply
Required
Please rate the child's current school performance *
failing
below average
average
above average
Reading
Writing
Math
Science
Spelling
BEHAVIOR PROBLEMS *
Does the child have any problems with behavior at school? Suspensions or expulsions?
Your answer
Describe homework time with this child *
Your answer
DISCIPLINE *
Is the child obedient? Who disciplines the child? What type of discipline works best?
Your answer
SOCIAL and EMOTIONAL FUNCTIONING *
Describe this child's social skills including any problems with friendships
Your answer
How does the child show affection? To whom and how often? *
Your answer
Compared to other children of the same age, how well does the child.. *
worse
average
better
don't know
get along with siblings?
get along with parents?
get along with other family members?
get along with peers?
What makes the child angry? What does he/she do when very angry? *
Your answer
What makes the child nervous? What does he/she do when very nervous? *
Your answer
What makes the child happy? What does he/she do when very happy? *
Your answer
Describe any compulsive or repetitive behaviors. *
Your answer
Describe any unusual or problematic behaviors not described previously.
Your answer
ACTIVITIES of DAILY LIVING *
How does the child like to spend his/her time? What does the child enjoy?
Your answer
List current extracurricular activities *
Your answer
What chores are the child expected to complete? Does this happen regularly? *
Your answer
Please include anything else about your case that you think is important for us to include in your report to help decide appropriate actions for your case? *
Your answer
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