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Intake form Teen & Child

Teen and Child Intake Form

Please complete the following questions BEFORE you book a time in the diary – It should take you no more than 4 minutes.

There are no right or wrong answers, just your thoughts.

Personal Contact Information

All of your Data is stored in a safe and secure online server which meets all Privacy legislation requirements

Name of the child or teenager *

First

Last

Parent Name / Carer Name *

First

Last

Adult Phone Number *

Adult Secure Email Address *

Address 1 *

Address 2 *

CIty *

State/County *

Post Code

Section 2 Emotional Health Questions

Are you able and willing to have Telehealth sessions?

Totally comfortable with Zoom / online sessions
I prefer using my phone
I prefer face to face

We may not be able to meet what you prefer, but at least we can talk about it. Young children below the age of 5 - I only offer face to face sessions.

Are you at school? What grade *

Do you have supportive people around you

Yes
No
Unsure

Have you ever been diagnosed with a mental illness / disorder? *

Yes
No

Are you currently on any medication? *

Yes
No
natural therapies

If yes, what medications are you taking?

Have you had mental health / emotional therapy before? *

Yes
No
Cannot remember

What form of therapy was it? *

Counselling
Psychotherapy with a psychologist or psychiatrist
Behaviour Modification sessions
Hypnotherapy - they read a script
Hypnotherapy - they did not read a script
I do not know

Are you currently having therapy? *

Yes
No

This is to ensure your therapies are complimentary, i.e are able to work together for your best outcome.

Has this child / teenager experienced any of the following in the past?

What would you like to change - or - what do you need help to change? (copy) *

General Anxiety
Performance Anxiety
School or study Stress
Social Anxiety
Depression
Chronic Insomnia
Eating Disorders or Problems
Behaviour Modification
Excessive Drinking
Trying Drugs
Family / Relationship Stress
Stress / Anger / Withdrawal due to custody dispute
Anger and explosive rage episodes
Trauma - Domestic Violence
Trauma / PTS
Other - Will tell you face to face

Does this child / teenager currently experience any of the following?

This is just to start our discussion.

What would you like to change - or - what do you need help to change? (copy) (copy) *

General Anxiety
Performance Anxiety
School or study Stress
Social Anxiety
Depression
Chronic Insomnia
Eating Disorders or Problems
Behaviour Modification
Excessive Drinking
Trying Drugs
Family / Relationship Stress
Stress / Anger / Withdrawal due to custody dispute
Anger and explosive rage episodes
Trauma - Domestic Violence
Trauma / PTS
Other - Will tell you face to face

Section 3 - Physical Health

Research shows there are close links between mental and physical condititons.

Medical Practitioner Name and Phone number

Does this child or teen have any physical conditions worrying them? *

Digestive System
Nervous System - including back and spinal
Hormone System
Respiratory System
Heart and Circulation System
Skin, hair or Nail System
Structure - bone System
Any long term treatment
Any future surgical treatment
Dental visits or treatments

Describe their quality of sleep? *

Good
Average
Poor
It depends
Been poor for ages
Issues of bed wetting

Do you know or suspect this teen or child smokes cigarettes? *

Yes
No
I have smelt it on their breath
I suspect they are e-vaping
Really do not know

Are you aware of any alcohol consumption? *

S/he does not drink alcohol at all
Occasionally at our home, with us, only
I have noticed the smell on their breathe occasionally
I have noticed the smell on their breathe often

Have you discussed these concerns with a medical practitioner?

Are you aware of any drug or narcotic consumption? *

S/he does not use narcotic drugs at all
The Parent in our house controls medicines and their use.
I have noticed the smell on their clothes and hair occasionally
I have noticed their behaviour has changed significantly
I have noticed their eye pupils have changed

Have you discussed these concerns with a medical practitioner?

Is there anything else you think I should know?

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