Adolescent Psychotherapy Intake – To be Completed by Adolescent
This form is intended to help your counselor become better acquainted with you and in turn, serve you better. You may omit any item, but try to be as thorough as possible. Please use the back if you need more space. Thank you. Client Name:___________________________________ Nickname:_____________________Date:__________ Date of Birth:___________________Age:__________Gender: □ Male □ Female Grade in school: _________ What brings you to therapy?:___________________________________________________________________
My current concerns/symptoms developed (Please Circle):
Suddenly (less than four weeks) Gradually (one to several months) Very Gradually (one to several years)
How would you describe your mood at this time?:___________________________________________________ What would you like to see change as a result of therapy?_____________________________________________ Have there been any significant changes in your life recently? □ Yes □ No If yes, please describe:__________ __________________________________________________________________________________________ What do you hope that will be different in your life as a result of coming to therapy?:________________________ __________________________________________________________________________________________
Do you have any concerns at this time about hurting yourself? □ No □ Yes If yes, please describe:_______________ _____________________________________________________________________________________________ Do you have any concerns at this time about hurting someone else? □ No □ Yes If yes, please describe:___________ _____________________________________________________________________________________________ Family Environment/Relationships – Your Living Situation
I live with: □ Biological Parents □ Adoptive Parents □ Parent and Step-Parent □ Foster Parents
□ One Parent Alone □ Relatives □ Other:___________________________________
Primary Household
Household Age Relationship Describe Relationship
Member Name to me
Do you live in more than one household? □ No □ Yes
If no, skip to “Secondary Household”. If yes, complete the secondary household information. Hope in Healing Counseling and Wellness, LLC
Stacy Nunne, MA, LAMFT, RN
KleinBank Building Mailing Address: PO Box 892
600 West 78th Street, Suite 10B Chanhassen, MN 55317 Chanhassen, MN 55317 e-mail: [email protected]
Secondary Household
Household Age Relationship Describe Relationship
Member Name to me
Additional family members living with you
Household Age Relationship Describe Relationship
Member Name to me
How would you describe your family?:____________________________________________________________ __________________________________________________________________________________________ What does your family do together?:_____________________________________________________________ __________________________________________________________________________________________ Describe how problems are generally handled in your family?: _________________________________________ __________________________________________________________________________________________ Where did you live growing up? (Please list all places):________________________________________________ __________________________________________________________________________________________ Have you experienced a death (family, friends, pets, etc.)? □ No □ Yes At what age(s)? ___________________ If yes, please describe your reaction:______________________________________________________________
Development History
Are there special, unusual, or traumatic circumstances that affected your development? □ No □ Yes
If yes, please describe: ____________________________________________________________________________ Do you have a history of abuse? □ No □ Yes
If yes, which type(s): ____ Sexual ____Physical ____Verbal ____Emotional ____Neglect
____ Inadequate Nutrition ____ Inadequate Medical Attention ____ Inadequate Dental Attention Is there anything else that happened to you that you consider abuse?:________________________________________
Did anyone in your family of origin experience childhood abuse? □ No □ Yes If yes, Whom:_________________
__________________________________________________________________________________________
Mental Health Treatment History
Have you experienced or witnessed any of the following? □ No □ Yes (Please check all that apply to you)
_____Car accident _____Community violence _____Bullying _____Domestic violence/abuse
_____Other accident _____Fire _____Natural disasters _____Significant loss
_____Physical illness _____Relationship Abuse _____Recent Death _____Loss of friendships
Behavioral/Emotional Health (Please check all of the following that apply to you):
____Affectionate ____Expect Failure ____Moody ____Slow Moving
____Aggressive ____Fatigued ____Neat/Orderly ____Speech Problems
____Anger Problems ____Fearful ____Nightmares ____Steal
____Anxiety ____Fearless ____Overweight ____Stomachaches
____Argue Excessively ____Frequent Injuries ____Phobias ____Stutter
____Avoids Adults ____Frustrated Daily ____Preoccupied with Things ____Teeth Grinding
____Bully/Threaten Others ____Generous ____Quiet or Withdrawn ____Tics or Twitching
____Careless/Reckless ____Have Bad Dreams ____Sad ____Tired Often
____Clumsy ____Hopelessness ____Selfish ____Underweight
____Confident ____Impulsive ____Self-Mutilation ____Unsafe Behaviors
____Cooperative ____Irritable ____Separation Anxiety ____Unusual Thinking
____Depressed ____Lazy ____Set Fires ____Withdrawn
____Destructive ____Learning Problems ____Short Attention Span ____Worry Excessively
____Difficulty Speaking ____Loner ____Shy/Timid ____Other____________
____Defiant ____Low Self-Esteem ____Sick Often ____Other____________
____Enthusiastic ____Messy ____Sleeping Problems ____Other____________
Please describe any of the above or any other concerns: ______________________________________________
Alcohol or Drug/Chemical Use -Please list the alcohol or drugs/chemicals that you have used - list how much:
Never Used Used in the Past Age Started Daily Weekly Occasionally Last Use
Caffeine Tobacco Alcohol Marijuana/THC Cocaine/Crack Inhalants/“Huffing” LSD/“Shrooms” Prescribed Pills Heroine Speed, Ecstasy Rohypnol-Roofies GHB-liquid ecstasy LSD Steroids Others: _________ Others: _________
If you use alcohol or Drugs/Chemicals:
Do you have any concerns about your use of alcohol? □ No □ Yes Drugs/Chemicals? □ No □ Yes Do you believe that you have a problem with alcohol? □ No □ Yes Drugs/Chemicals? □ No □ Yes If yes, how long have you gone without using alcohol or drugs/chemicals?____________________________ Are others concerned about your alcohol use? □ No □ Yes Drugs/Chemical use? □ No □ Yes
Have you ever been in treatment for alcohol or chemical dependency? □ No □ Yes If yes, where? Treatment Center/Hospital (Include inpatient, outpatient, detox) Dates
____________________________________________________________ _____________________________ ____________________________________________________________ _____________________________ Did you learn anything that was helpful ? □ No □ Yes Please describe what you found to be helpful:
__________________________________________________________________________________________
Are you currently seeing a psychiatrist? □ No □ Yes
Psychiatrist:______________________________________ Is he/she helpful?:___________________________ Have you ever been hospitalized for psychiatric reasons? □ No □ Yes
Hospital Reason for Hospitalization Dates
________________________________ _____________________________ __________________________ ________________________________ _____________________________ __________________________ ________________________________ _____________________________ __________________________ Have you ever been under the care of a therapist? □ No □ Yes If so, with who and when?
Therapist Approximate Dates Helpful?
________________________________ _____________________________ __________________________ ________________________________ _____________________________ __________________________ ________________________________ _____________________________ __________________________ Is there a family history of a problem with alcohol? □ No □ Yes Drugs/Chemicals? □ No □ Yes
Please indicate A-alcohol D- Drugs/Chemicals
______Mother ______Father ______Sibling_________________
______Maternal Grandmother ______Paternal Grandmother ______Sibling_________________
______Maternal Grandfather ______Paternal Grandfather ______Sibling_________________
______Maternal Aunt ______Paternal Aunts ______Other_________________
______Maternal Uncle ______Paternal Uncles ______Other_________________
General Health Information (Please put C-Current and/or P-Past for all that apply to you):
____Abdominal pain ____Diabetes ____Headaches ____Skin Problem
____ADHD ____Disability ____Heart trouble ____Sleeping Problems
____Allergies ____Dizziness ____Memory Impairment ____Speech Problems
____Asthma ____Excessive Sweating ____Migraines ____Stomach Trouble
____Neck/Back pain ____Eye Problems ____Numbness/Tingling ____Tics/Tremors
____Blackouts ____Fainting Spells ____Pain-Where?_________ ____Wears glasses
____Chest Pains ____Fatigue ____Respiratory illness ____Other___________
____Colds/Coughs ____Hearing Loss ____Seizures ____Other___________
____Dental problems ____Head Injury ____Severe Head Injury ____Other___________
Please list any current health concerns or problems OR any changes in your health?:_________________________ __________________________________________________________________________________________
Have you ever had any seizures or head injuries? □ No □ Yes If yes, please describe:____________________
__________________________________________________________________________________________ Please check if you have noticed/experienced any recent changes in the following:
____ Sleep patterns ____ Eating patterns ____Behavior ____Energy level
____ Physical activity level ____ General disposition ____ Weight ____Nervousness/tension
Sexual History
Are you currently sexually active? □ No □ Yes Have you been sexually active in the past? □ No □ Yes
Do you have any concerns about your sexual development? □ No □ Yes Please explain:___________________ __________________________________________________________________________________________
Education
Current school:______________________________________________How long attended?:_______________ Type of school: □ Public □ Private □ Home schooled □ Other (please specify):_____________________ Grade: ______ Teacher: ______________________ School Counselor: _________________________________ Previous Schools:___________________________________________________________________________ __________________________________________________________________________________________ Do you have any learning problems?:_____________________________________________________________ Which subject/areas interest you the most in school?:________________________________________________ __________________________________________________________________________________________ Which subject/areas interest you the least in school?:________________________________________________ __________________________________________________________________________________________ What grades do you typically receive in school?:_____________________________________________________
Have there been any changes in your grades? □ No □ Yes If yes, please describe:________________________
__________________________________________________________________________________________ Performance in school (by your report): ____Satisfactory ____ Underachieve ____Overachieve
Please check below the words that best describe you in regards to school performance:
____Anxious ____Disorganized ____Interested ____Responsible
____Bored ____Eager ____Lack of Initiative ____Self-Directed
____Cooperative ____Enthusiastic ____Organized ____Sloppy
____Disinterested ____Industrious ____Passive ____ Does only what is expected
____Other (please describe):___________________________________________________________________ Do you have any problems with teachers or other classmates? □ No □ Yes If yes, please describe:___________ __________________________________________________________________________________________ Please check below the words that best describe your peer relationships:
____Spontaneous ____Follower ____Leader
____Have Difficulty Making Friends ____Have Few Friends ____Have a Lot of Friends ____Make Friends Easily ____ Have Long-Time Friends ____Have a Few Good Friends ____Other (please describe): _______________________________________________________________ Please describe your friendships:________________________________________________________________
Culture/Ethnicity
To which cultural or ethnic group, if any, do you consider you belong?:__________________________________
Are you experiencing any problems due to cultural or ethnic issues? □ No □ Yes If yes, please describe:______
__________________________________________________________________________________________ Is there any other cultural/ethnic information you want your therapist to know? ___________________________ __________________________________________________________________________________________
Spiritual/Religious
How important are spiritual matters to you? ____ Not at all ____ A little ____ Somewhat ____ Very
Is your family affiliated with a spiritual or religious group? □ No □ Yes
If yes, please describe: ________________________________________________________________________
Would you like your spiritual/religious beliefs included in counseling? □ No □ Yes
If yes, please describe: ________________________________________________________________________
Internet
How much time do you spend on the internet/phone/IPod/video games a day?:_______hours
Does media use interfere with school work? □ Yes □ No Job? □ No □ Yes Family time? □ No □ Yes Friendships? □ No □ Yes Extra-curricular activities? □ No □ Yes
Leisure/Recreational
Please describe your family’s areas of interests or hobbies that you do together:____________________________ __________________________________________________________________________________________ Please describe your areas of interest or hobbies (e.g., art, books, bowling, church activities, crafts, fishing, hunting outdoor activities, school activities, school clubs, school sports, scouts sports (outside of school), working out, etc.) Activity How often I How often I have
participate? participated in the past?
___________________________ ___________________________ ___________________________________ ___________________________ ___________________________ ___________________________________ ___________________________ ___________________________ ___________________________________ ___________________________ ___________________________ ___________________________________ ___________________________ ___________________________ ___________________________________
Current Employment Status
Do you have a job? □ No □ Yes □ Full Time □ Part Time Where?________________________________ Do you have any concerns about your work environment? □ No □ Yes Please explain:____________________ __________________________________________________________________________________________
Legal History
Do you have a history of legal charges? □ No □ Yes If so, please describe _____________________________ __________________________________________________________________________________________
Do you have involvement with any of the following people or services? □ No □ Yes
If yes, please circle all that apply:
County Social Worker Probation Officer Adult/Child Protection Guardian Ad Litum
If so, please describe:_________________________________________________________________________ __________________________________________________________________________________________
Additional Personal Information
Is there any additional information that you believe would help me in understanding you?:____________________ __________________________________________________________________________________________ Is there any additional information that would help me understand your current concerns or problems?:_________ __________________________________________________________________________________________ Is there anything else that you would like me to know about your family?:_________________________________ __________________________________________________________________________________________ What are your goals for therapy? ________________________________________________________________ Is there anything else that you think would help you to have a positive therapy experience?:___________________ __________________________________________________________________________________________ Client Signature:__________________________________________________________ Date:______________
