Has your child ever tried, or does your child currently use, any chemical substances? Please list alcohol, tobacco, illegal substances, over-the-counter medications and prescription medications.

Please complete this form as honestly and completely as possible. All information that you provide us will be confidential as required by state and federal law.

In the first two years, did your child experience: ___Separation from mother, ___Out of home care, ___Disruption in bonding, ___Depression of mother, ___Abuse,

Your signature below indicates that you have read and understand this information and have received a copy of this consent form and give permission to MFS/TAC to provide counseling …

What are your child’s regular responsibilities at home? (feeding the dog, laundry, cleaning their room etc.) __________________________________________________ What method(s) do …

Has this child/adolescent ever had any emergency room visits for emotional or behavioral problems? Yes No If yes, please specify the reason, date, outcome and name of hospital.

What is your current diet, weight, and exercise/activity patterns? What are your hobbies, talents, and strengths?

Please list any significant stressors your child has experienced (job change or loss, family illness or injury, accidents, deaths, moves, violence, crime victimization, etc.)

This form authorizes Viewpoint Psychology and Wellness, LLC to make a debit to your credit card listed below, at any time, for any co-pays, deductibles, private pay, insurance deemed patient …

View, download and print Child Intake pdf template or form online. 37 Intake Form Templates are collected for any of your needs.