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Child Intake Form
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What is the reason for the referral?
Has your child been evaluated before?
What are the presenting problems?
When did the problems begin?
Where do they occur?
Does anything relieve or reduce the reported problems or symptoms?
Please list all of your child's prescription medications
Have there been any significant events or stressors in the child's home or family? Please describe.
How do you think your child's problems affect their daily performance at school? at home? in other settings?
When was your child's most recent medical exam?
Please list all medical conditions if applicable
How would you describe your child's overall health?
Does your child have visual or hearing difficulties?
Describe your family composition. Who lives in the household?
What is the family's ethnic and cultural background?
Please indicate family's income status
My child has problems with... (check all that apply)
staying on task
respect for authority
aggression towards others
getting dressed in the morning
falling asleep at night
How does the family handle the child's problems?
How does your child spend their free time?
What responsibilties/chores does your child have at home?
What are your child's strengths?
What type of interventions, including services would you like to receive for your child?
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'Dreams are merely visions waiting to happen.'
-Danielle Leach, author of American Dreamer/founder of Dream Pathways