Intake Form – Child/Adolescent/Young Adult - Compass for Life - Gayle Saifert D.C.S, RSWCompass for Life

Client Information

Client name: *

Gender: *

Date of Birth: *

day

/

month

/

year

Mailing address:

Street Address City State / Province / Region Postal / Zip Code Country

Home #:

Business #:

Cell #:

Email: *

Emergency contact:

Address:

Street Address City State / Province / Region Postal / Zip Code Country

Home #:

Cell #:

Email:

Parent/Guardian Information

Parent 1:

Address:

Street Address City State / Province / Region Postal / Zip Code Country

Parent 2: (if applicable)

Address

Street Address City State / Province / Region Postal / Zip Code Country

Additional Parent information (if applicable):

Which email address should be used for billing purposes:

If this is a separated family, please indicate which parent will serve as the primary contact for billing purposes:

Others at this address (i.e. siblings, grandparents)

Name:

Relationship / age:

Name:

Relationship / age:

Name:

Relationship / age:

Name of Family Doctor:

Telephone #:

Address:

Street Address City State / Province / Region Postal / Zip Code Country

Name of Treating Psychiatrist (if applicable):

Why are you are seeking treatment for your child or teen right now? (please include when the problem began):

Has your child/teen been diagnosed by a physician or psychiatrist with ADD, Learning Disability or any other mental health diagnosis? If so please elaborate with details of date of diagnosis and clinician who completed the diagnosis.

Is your child/teen taking any medications? If so please provide details including prescribing physician.

School History

Name of School 1:

Grades:

Primary contact:

Name of School 2:

Grades:

Primary contact:

Name of School 3:

Grades:

Primary contact:

Name of School 4:

Grades:

Primary contact:

Name of School 5:

Grades:

Primary contact:

Name of School 6:

Grades:

Primary contact:

Name of School 7:

Grades:

Primary contact:

Name of School 8:

Grades:

Primary contact:

Has your child or teen had an Individualized Education Plan in place now or in the past, if so please describe:

Has your child or teen had a psycho-educational assessment? If so please provide details below (diagnosis, date and assessor and if possible attach or send the report in a separate email)

How would you describe your child or teen’s study habits?

Please indicate which issues your child or teen has struggled with in the past or present:

Anxiety

Past or present?

Text1

Panic

Past or present? (1)

Text1(1)

Phobia

Past or present? (1)(1)

Text1(1)(1)

Sadness

Past or present? (1)(1)(1)

Text1(1)(1)(1)

Irritability

Past or present? (1)(1)(1)(1)

Text1(1)(1)(1)(1)

Poor Concentration

Past or present? (1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)

Relationships

Past or present? (1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)

Self Harm

Past or present? (1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)

Binging / Purging / Food Restrictions

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)

Appetite Change

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)

Anger

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Suicidal Thoughts

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Social Withdrawal

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Alcohol Use

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Recreational Drug Use

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Prescription Drug Use

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Sleep Issues

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Fatigue

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Use of Sleep Aids

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Change in Appetite

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Poor Relationships

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Self Injury

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Risky Sexual Behaviour

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Problems at Work

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Intrusive or Unwanted Thoughts

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Compulsive Behaviours

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Rituals that seem to be unusual or are interfering with day to day functioning

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Any other concerns:

Any other concerns

Past or present? (1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Text1(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)(1)

Has Child Protection Services been involved in your family in the past? (If so please provide details)

Please list any helping professionals you have been involved with your child or teen in the past or present. (Include dates and any current involvement)

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Name of Practitioner

Date

Outcome

Is there a history of self harm, (cutting, eating disorder, suicidal thoughts or attempts?)

Family History

Have any other family members struggled with mental health? (please describe)

Do any family member have issues with substance or addiction? (please describe)

Has any other family members struggled with learning, attention, or hyperactivity?

Please describe family relationships:

Please describe your child or teen’s primary relationships (how they get along with friends and family)

What are your child or teens hobbies?

How would you describe your child or teen’s strengths?

Have you noticed anything that provides relief from your child or youth’s presenting concerns?

Please list how you hope the treatment will help

Additional Information In the space below, please share any other details that would help me understand your child or teen better.

Electronic Communication

The use of electronic communication is used primarily for the purpose of billing and coordinating contact. The transmission of information via email or text may unintentionally limit the protection of confidentiality. More specifically, networks are not secure, emails are not encrypted and emails can be sent to unintended recipients without the sender’s intent. Given these risks, I agree to use email to communicate for billing and the purpose of coordinating contact.

Initials*

How did you find me?*

I consent collecting this data and processing it according to Privacy Policy of this website.

Intake Form – Child/Adolescent/Young Adult

Client Information

Parent/Guardian Information

School History

Family History

(416) 333 – 0640

gayle@compassforlife.ca

Linkedin

© 2014 Compass for Life. Gayle Saifert D.C.S, RSW
Website by Young Seagull

Intake Form – Child/Adolescent/Young Adult

Client Information

Parent/Guardian Information

School History

Family History

(416) 333 – 0640

gayle@compassforlife.ca

Linkedin

© 2014 Compass for Life. Gayle Saifert D.C.S, RSW Website by Young Seagull

© 2014 Compass for Life. Gayle Saifert D.C.S, RSW
Website by Young Seagull