Teen Intake Form

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Please call 815-290-9711 BEFORE completing this form to ensure we can meet your needs and have an opening.

This form should be completed by the guardian of the teen desiring counseling.

Did you speak to someone at Renew before completing this form?* Yes

Name of person completing this form*

Relationship to teen*

Phone number of guardian*

Email address of guardian requesting the appointment*

Teen's Name*

Teen's Gender* Male Female

Teen's Date of Birth*

Teen's Street Address*

Teen's City*

Teen's State*

Teen's Zip Code*

Teen's school*

Grade*

Biological Father Information (If no contact please indicate. Provide as much info as you are comfortable)

Biological Father's Name*

Biological Father's Age

Biological Father's Marital Status

Biological Father's Occupation

Biological Father lives with child?* Yes No

If no, how often does the child see the biological father?

Biological Mother Information (If no contact please indicate. Provide as much info as you are comfortable)

Biological Mother's Name*

Biological Mother's Age

Biological Mother's Marital Status

Biological Mother's Occupation

Biological Mother lives with child?* Yes No

If no, how often does the child see the biological mother?

Does the child have other regular caregivers (step parent, grandparent, other family member, friend, etc.)?* Yes No

If yes, please list and explain

Is the child adopted? Yes No

If teen is adopted, please complete this section. Leave this section blank if the teen is NOT adopted.

Father's Name

Father's Age

Father's Marital Status

Father's Occupation

Father lives with child? Yes No

If no, how often does the child see the adoptive father?

Mother's Name

Mother's Age

Mother's Marital Status

Mother's Occupation

Mother lives with child? Yes No

If no, how often does the child see the mother?

Child Intake Form

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Please list the names of ages of ALL those who live in the same household as the teen (siblings, other family members, etc.)

Counseling Data

Teen's Primary Care Doctor

Primary Care Doctor Phone

Teen's Psychiatrist (if applicable)

Psychiatrist's phone

Who referred you to counseling?

Has your teen ever been to counseling before?* Yes No

If yes, please list when, with whom, and why

Why are you seeking counseling for your teen at this time?

When did you first notice the problem(s)?

How does your teen feel about the problem?

Child Intake Form

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Counseling Data

What do you think it will take to make the problem better?

Has your teen ever abused medication, drugs, or alcohol?* Yes No

Is yes, please describe

Has your teen ever talked about hurting him/herself or anyone else?* Yes No

If yes, please describe

How does your teen usually cope when under stress (tries to solve problem, becomes anxious, cries, shuts down, becomes angry, seeks out adult help, etc.)?

Developmental History

If your child was adopted, answer to the best of your ability or write "unknown."

How did the parents feel when they found out mom was pregnant?

Was the child planned? Yes No

Please check all that occurred during the mother's pregnancy with this teen: Smoking
Drinking alcohol
Marijuana use
Cocaine / Crack use
LSD use
Other street drug

If any checked above, please list frequency

Please check all that occurred during the mother's pregnancy with this teen: Physical abuse of mother
Extreme stress
Major illness of mom
Major injury to mom
Irregular prenatal care
Mom depressed

Any complications during pregnancy?

Any complications during birth?

Child Intake Form

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Developmental History

Any complications soon after birth or in first year of life?

Teen's birth weight

Premature birth?* Yes No

If yes, how many weeks premature?

Would you say your teen developed faster, slower, or at about the same rate as other children?

If your teen was adopted, please share the adoption story.

Age when adopted

Local or Foreign adoption Local Foreign

Circumstances leading to adoption (why did family want to adopt?)

How does the teen feel about being adopted (in the past and today)?

In your opinion, does the fact that the teen was adopted have anything to do with circumstances leading you to counseling? Yes No

Additional comments you would like to share

Child Intake Form

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Medical History

Please list any medication the teen is taking, doses, prescribing Doctor, and the reason for taking each medication

Please list (name only) any past medications this teen took for behavior or psychological problems

Please list any surgeries or hopsitalizations

Family History

Please describe the child's relationship with the following

Father's parents Excellent
Good
Fair
Poor

Mother's parents Excellent
Good
Fair
Poor

Siblings Excellent
Good
Fair
Poor

Aunts / Uncles Excellent
Good
Fair
Poor

Cousins Excellent
Good
Fair
Poor

Other relationship

Other Excellent
Good
Fair
Poor

Child Intake Form

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Family History

Does anyone in the child's immediate or extended family have the following problems (brother, sister, parent, grandparent, aunt, uncle, cousin)?

Depression* Yes No

Who had problem?

Nervous Breakdown* Yes No

Who had problem?

Delayed reading* Yes No

Who had problem?

Mental retardation* Yes No

Who had problem?

Hyperactivity* Yes No

Who had problem?

Drug abuse* Yes No

Who had problem?

Stealing* Yes No

Who had problem?

Epilepsy* Yes No

Who had problem?

Anxiety* Yes No

Who had problem?

Aggressive* Yes No

Who had problem?

Autism* Yes No

Who had problem?

Insomnia* Yes No

Who had problem?

OCD* Yes No

Who had problem?

Manic* Yes No

Who had problem?

Psychiatric hospital stay* Yes No

Who had problem?

Delayed speech* Yes No

Who had problem?

Attention problems* Yes No

Who had problem?

Heavy drinking* Yes No

Who had problem?

Suicide* Yes No

Who had problem?

School problems* Yes No

Who had problem?

Criminal behavior* Yes No

Who had problem?

Bedwetting* Yes No

Who had problem?

Schizophrenia* Yes No

Who had problem?

Eating disorder* Yes No

Who had problem?

Genetic disorder* Yes No

Who had problem?

Other* Yes No

Who had problem?

How is discipline handled in the family (grounding, take away privileges, spanking, etc.)?

Who is most responsible for discipline? (Mom, Dad, Both, Other)

Describe the family's spirituality (go to church, believe in God, atheist, pray, etc.)

Is the teen's spirituality the same as the family's?* Yes No

Are there any current family stressors that may affect the child (divorce, fighting, job loss, illness, recent change, etc.)?

Child Intake Form

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Please indicate if any of the following have occurred in the family:

Parental divorce* Yes No