SADAR PSYCHOLOGICAL AND SPORTS CENTER

Child and Adolescent Intake Questionnaire

Child’s Name: _________________________________ Child’s Date of Birth: _____________________

Child’s Dominant Hand: R L Ambidextrous Child’s Age: ____________________________

Your Name(s): _________________________________ Relationship to Child: _____________________

Presenting Problem
1. What is your major concern that led you to seek help?
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2. What other concerns do you have?

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3. Is there a particular reason you are seeking an appointment now?

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Prior Treatment
4. Has the child ever had a psychological evaluation or had intellectual or achievement testing at school?
□ No □ Yes If yes, please describe when, with whom, and the results.
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5. Has the child ever been in counseling, or have you ever sought help for these problems before?
□ No □ Yes If yes, please enter the information below.

Date(s) and number of visits of most recent counseling:

Counselor:

Explain what happened and the results:

Date(s) and number of visits of any earlier counseling:

Counselor:

Explain what happened and the results:

Medication
6. Has the child ever taken medication for attention, behavior or mood problems?
□ No □ Yes If yes, fill out the table below as completely as possible for each medication.

Medication

Dose

Reason prescribed

Dates Taken

Prescribing Physician

Benefits

Problems

If discontinued, why?

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 Medical History
7. Has the child been to the doctor in the last year?
□ No □ Yes If yes, were the current concerns discussed? Were recommendations made?
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8. How is the child’s health currently? Is he/she being treated for anything?
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9. Does the child get headaches? Please describe the type, frequency, and severity.
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10. What medical or physical problems has the child had? Mark an X where appropriate:
Very sensitive to feel of labels, Birth to 5 6-12 13-18 19-24 25-50 50+
seams, textures in clothes - ______ ______ ______ ______ ______ ______

Allergies or food sensitivities - ______ ______ ______ ______ _____ ______

Ear infections, frequent colds - ______ ______ ______ ______ ______ ______
Poisoning or drug overdose - ______ ______ ______ ______ ______ ______
Serious illnesses or surgeries - ______ ______ ______ ______ ______ ______
Vision/hearing difficulties (not glasses)- _____ ______ ______ ______ ______ ______
Speech disorders - ______ ______ ______ ______ ______ ______
Serious accidents/Injuries - ______ ______ ______ ______ ______ ______
Any blows to the head or concussions-______ ______ ______ ______ ______ ______
Any loss of consciousness or seizures- _____ ______ ______ ______ ______ ______
Bothered by loud/unexpected noises - ______ ______ ______ ______ ______ ______
Very picky eater - ______ ______ ______ ______ ______ ______

Please describe any X that was marked.

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11. List any medications/supplements the child is currently taking in the columns below.

Medication

Dose

Purpose

Date Started

Prescribing Physician

Side Effects

Developmental History
12. Were there any problems or unusual circumstances during pregnancy, delivery or first months of the child’s life?
□ No □ Yes □ Don't know If yes, please describe.
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13. Was the child adopted? □ No □Yes If yes, at what age? ____________________
What age was the child informed he or she was adopted? __________________________________________

14. Were there any developmental problems including delay in learning to crawl, walk or talk?
□ No □ Yes □ Don't know If yes, please describe.
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15. As an infant, were the child difficult, demanding, hard to soothe, colicky or had problems sleeping?
□ No □ Yes □ Don't know If yes, please describe.
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16. Were there any disruptions or major difficulties that could have affected the child’s bonding with his or her mother
during the first three years?
□ No □ Yes □ Don't know If yes, please describe.
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17. As a child, was he/she said to have been extremely physically active or always “on the go”?
□ No □ Yes □ Don't know If yes, please describe.
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 Psychosocial history
18. Please describe ONE, any of the following the child experienced, TWO, the impact you felt the events had on the
child then and THREE, how you feel it may be affecting the child now.

Problem Areas Age(s) (1) Nature of event, (2) Impact THEN, (3) Impact NOW

Problems in the family such as

separation, divorce or remarriage;

psychiatric, alcohol or drug

problems of parent, death or

serious health problems of family

member; change in living

arrangements

Emotional, physical, or sexual

abuse; neglect, or exposure to

domestic violence or on-going

intimidation, harassment,

discrimination

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 Problem Areas Age(s) (1) Nature of event, (2) Impact THEN, (3) Impact NOW

Problems with housing, living

arrangements, such as

homelessness or frequent moves

or sudden loss of family income

Problems in social network such

as death or loss of close friends

rejection by peers, or frequent

moves causing loss of friends

Educational problems including

learning problems, academic

problems, inadequate schooling

Problems related to the legal

system, or interaction with the

police, being a victim of a crime

or a ward of the court

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 Problem Areas Age(s) (1) Nature of event, (2) Impact THEN, (3) Impact NOW

Chronic medical problems,

illness or surgeries

Exposure to disaster, accidents

or other trauma

Social relations and support

19. What are the child’s current living arrangements? Please list siblings’ ages and marital status of the parents. If the
parents are divorced, who has custody and what are the visitation arrangements?
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20. How well does the child get along with his or her parents?
Mother:_____________________________________________________________________________________
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Father:_____________________________________________________________________________________
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21. If the child is not living with both natural parents, how are the relationships with the non-custodial parents?
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22. If the birth parents are separated, how well do they get along, especially in regards to the child?
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23. How well does the child get along with siblings?
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24. How well does the child get along with friends and peers?
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25. Does the child have problems with understanding or expressing emotions? Does the child have problems with
social awareness?
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School and Work History
26. Which school does your child currently attend? ___________________________________________________
27. What is the furthest grade reached or highest degree your child attained in school? ______________________
28. What was the Grade Point Average in your child’s most recent schooling? _______________________________
29. Please describe your child’s greatest strengths and any special abilities or talents. In what school subjects has he
or she generally done best?

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30. Please circle any of the following that are current problems:
Difficulty learning to read, blend sounds or read smoothly Difficulty spelling

Problems tracking while reading (losing place, missing words) Poor handwriting (even if writing slowly)

Difficulty remembering what was read Difficulty drawing or copying figures

Difficulty with math calculations Poor sense of direction

Difficulty understanding math concepts Difficulty at written composition

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31. Please mark with an "X" when any of the following has occurred.
Elementary School Middle School High School College
Reading difficulties ________ ________ ________ ________
Math difficulties ________ ________ ________ ________
Writing difficulties ________ ________ ________ ________
Poor grades ________ ________ ________ ________
Homework problems ________ ________ ________ ________
Behavior problems at school ________ ________ ________ ________
Peer Problems ________ ________ ________ ________
Strongly disliked school ________ ________ ________ ________
Resource or other remedial assistance ________ ________ ________ ________
Special Education placement ________ ________ ________ ________
On Individualized Education Plan (IEP) ________ ________ ________ ________

32. What things have you tried at home to solve any of the problems noted above?
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Attention problems
33. What problems does the child have with daydreaming, staying on-task or being disorganized? At what age did you
first notice this? Do the problems occur mainly at home, at school or work or in all places?
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34. What problems does the child have with hyperactivity, stimulus seeking or feeling restless? At what age did you first
notice this? Do the problems occur mainly at home, at school or work or in all places?
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35. What problems does the child have with impulsivity, impatience or acting without thinking of consequences? At
what age did you first notice this? Do the problems occur mainly at home, at school or work or in all places?
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 Oppositionality, anger and conduct problems
36. What problems does the child have with being asked to do small tasks or requests? Is he or she easily irritated by
such requests?
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37. If asked to do 10 things during the day, how many would they do correctly on the first request, without arguement or
delay? _____ How much do you feel that any problems in this area come from not liking to be told to do things versus
being distractible or disorganized?
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38. What problems does the child have with irritability and anger? When angry, is the child more likely to let the anger
go quickly or hold onto resentment?
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39. Does the child ever become violent or destructive? Has he or she ever hurt anyone intentionally or threatened to kill
someone? Has he or she ever been cruel to animals? What interest does the child have in weapons?
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40. What problems does the child have with getting into trouble, unlawful activity or delinquent actions that could cause
legal consequences?
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41. In relating to others, what problems, if any, does the child have in terms of lacking empathy, being manipulative or
failing to show remorse when appropriate?
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Depression
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 42. What problems does the child have with their feelings being too easily hurt? Are there any signs of problems with
self-esteem? Are there particular things about him/herself the child feels especially bad about?
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43. What problems, does the child have with sadness, moodiness, withdrawing from friends or activities, appearing
down, lacking motivation or enthusiasm, changes in eating pattern, or crying easily?
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44. Does the child ever talk about wishing they were dead or discussed attempted suicide?
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Anxiety
45. What problems does the child have with fears, tension, anxiety, panic attacks, phobias, being very uncomfortable
in new situations or extreme shyness? How has that changed over time?
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46. Has anything ever happened to the child that when recalled causes them extreme distress? Are there any such
events that continue to cause bad dreams?
□ No □ Yes If yes, please describe.
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47. Are there any ideas, fears or concerns about which the child obsesses or worries?
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48. Does the child have any habits, rituals or other compulsive behaviors?
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49. What problems does the child have with muscle or verbal tics? These are repetitive movements or noises such
as eye blinking, facial twitching, or noises such as grunting, snorting, squeaking, or humming.
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Somatic Problems
50. Has the child ever struggled with chronic pain, sickness, or medical problems over the course of their life?
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51. Does stress in the child’s life cause physical symptoms such as tummy aches, back or neck aches, headaches,
intestinal problems or dizziness?
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Other Problems
52. Does the child, though not shy, prefer to be alone are show little interest in having close relationships with peers
outside family?
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53. Is the child’s style of speech “odd” (too exact, unusual tone or too formal)?
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54. Does the child tend to become overly fascinated by one particular topic, or become an expert in one particular
subject to the point that it is all they want to talk or learn about?
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Substance use

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55. Does the child use tobacco? □ No □Yes If yes, how much?
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56. Does the child drink coffee/soda/caffeinated beverages? □ No □Yes

Per day: ___________________________________________________________________________________
Per week:___________________________________________________________________________________

57. Do you have any knowledge or suspicion that the child has consumed alcohol?
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58. Do you have any knowledge or suspicion that the child has used drugs?
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TV/Video Games
59. How many hours a day/week does the child watch television? What are the child’s favorite shows to watch? How
many hours does the child watch in a single sitting?
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60. How many hours a day/week does the child play videos games? What are the child’s favorite games to play?
How many hours does the child play in a single sitting?
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Diet
61. How healthy is the child’s diet? What problems, if any, has the child had with sugar cravings, dieting or
maintaining weight? Has the child ever tried any special diets?
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Sleep
62. Please circle any of the following sleep problems that the child experiences and then describe the severity or
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 frequency in the space below:
Delays going to bed Not rested after sleep Teeth grinding
Difficulty falling asleep Nightmares (bad dreams) Snoring
Difficulty waking in morning Sleeping too much Bedwetting
Physically restless sleep Frequent waking Sleep Apnea
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Exercise
63. How much activity or physical exercise does the child get?
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64. (Females only) what problems, does the child have with unusual depression, irritability or discomfort during the
week or so before the menstrual period?
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65. Is there anything else it would be helpful to know about?

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 Family History

66. For each of the following, please identify any relatives of the child (siblings, parents, grandparents, aunts or
uncles) who may have had problems in these areas (i.e. "One of Mom's sisters took medication for depression.",
"One of Dad's brothers drank heavily from age 15 to 40 and then went into treatment").

Check here if father’s family history is unknown. ( ) Check here if mother’s family history is unknown. ( )
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Problems with attention including
being distractible, hyperactive or
impulsive.
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Problems in school or problems learning to read,
write or do math.
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Problems with opposionality,
anger, violence or criminal behavior
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Depression

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Anxiety

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Headaches/migraines/
seizures/neurological problems
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Alcohol Problems
Drug abuse
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Serious health problems

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Other mental or emotional illness

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Thank you for completing this form!