Child and Adolescent Intake Form

HomeChild and Adolescent Intake Form

All new patients MUST speak to Dr. Zametkin before making an appointment.

Please fill out all fields to the best of your ability. All required fields must be filled, even if the best you can do is enter “Not Applicable”.

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Patient Information

Disclaimer: *

This intake form is utilized for screening purposes, not treatment purposes. It is typically reviewed within 48 business hours of form submission. If your child is currently in crisis, please call 911, go to your nearest emergency room, or reach out to one of the following 24/7 resources: Call the National Suicide Prevention Lifeline at 1- 800-273-8255 or Spanish/Español: 1-888-628- 9454; Text the National Crisis Textline, text CONNECT to 741741; or call the National Suicide and Crisis Hotline at 988.

Date Completed *

Patient Name *

First

Middle

Last

Patient Date of Birth *

Email *

Sex *

If other, please specify

Person Completing this Form

First

Middle

Last

Relationship to Patient *

Briefly describe the conditions of your guardianship:

Your Email Address (NOT the child or adolescent's email address) *

Your Phone Number (NOT the child or adolescent's phone number) *

Does the child attend school, daycare, or is otherwise in someone else's care during the week? (CHOOSE ALL THAT APPLY) *

Public School
Private School
Daycare
After care
Before school care
Nanny/relative/babysitter at home
Homeschool
Homeschool Partnership

Name of School and County:

Name of daycare/before school care/after care facility:

Name of caretaker:

First

Last

Relationship of caretaker to child:

Is your homeschool: (Choose all that apply)

Entirely in your own home
Split between one or more family’s homes
Run from a public facility/religious facility/community center
Taught by you and/or your spouse exclusively
Taught by you with other teachers as well (ie. another family parent, religious leader, community member, etc…)
Taught by other teachers exclusively (ie. another family parent, religious leader, community member, etc…)
Includes only children from the child’s live in family.
Includes children from outside the home.
Other

Please describe the conditions of your child's homeschool:

Address the child lives at: *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Is the phone number for the child's home different from your own (that you have entered above)? *

Phone number for child's home:

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Parent/Guardian #1

Parent/Guardian #1: Are you the child's parent or guardian? *

Parent/Guardian #1 Name

First

Middle

Last

Parent/Guardian #1's Sex *

If other, please specify

Parent/Guardian #1's Phone Number

Parent/Guardian #1's Email

Parent/Guardian #1's Relationship to Patient

Briefly describe the conditions of Parent #1's guardianship:

Parent/Guardian #1's Age *

Parent/Guardian #1's Educational Background *

Is Parent/Guardian #1 Currently Employed? *

Parent/Guardian #1's Primary Work Title

Parent/Guardian #1's Primary Employer

Does the child live with a second parent or guardian? *

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Parent/Guardian #2

Parent/Guardian #2's Name

First

Middle

Last

Parent/Guardian #2's Sex

If other, please specify

Parent/Guardian #2's Phone Number

Parent/Guardian #2's Email

Parent/Guardian #2's Relationship to Patient

Briefly describe the conditions of Parent #2's guardianship:

Parent/Guardian #2's Age

Parent/Guardian #2's Educational Background

Is Parent/Guardian #2 Currently Employed?

Parent/Guardian #2's Primary Work Title

Parent/Guardian #2's Primary Employer

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Living Arrangements

Child currently lives with: *

Both Parents
Father
Mother
Father and Step Parent
Mother and Step Parent
Single Appointed Guardian
Married Appointed Guardians
Other

Please explain the child's current living arrangements

Is this child currently subject to a custody agreement? *

Yes
No
Divorce in progress, custody to be determined

How often does the non-custodial parent see the child?

Weekly or more often
Once or twice a month
Few times a year
Never

Please detail your expected custody agreement, and include what has been explained to the child up to this point.

Is there a reason (legal or otherwise) that the non-custodial parent never sees the child? What has been explained to the child about these circumstances up to this point?

Was this child adopted? *

How old was the child when they were adopted?

Where was the child adopted from?

Does the child know that they are adopted?

Yes
No
Unsure

What does the child feel about this fact? What has been discussed either privately with the child or as a family about the child's adoption?

Do you intend to ever tell the child? What reasons have held you back from explaining the circumstance to the child?

Current Family

Please enter the name and ages of everyone living in the house with the child OTHER than the parents or appointed guardians. Please also include their relationship to the child (ie. sibling, uncle, nephew, second cousin, etc.). *

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Presenting Concerns

What concerns led you to schedule this appointment? *

How long has the child been experiencing or exhibiting this/these issues? *

Has the child had issues like this/these before, and if so when? Could you describe the prior circumstance(s)? *

What are your goals for this visit? *

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Developmental History

Prenatal History

During pregnancy, did the biological mother experience significant stress? *

Yes
No
Unsure

Did the biological mother use any medications during her pregnancy? *

Yes
No
Unsure

Did the biological mother use any substances or alcohol during her pregnancy? *

Yes
No
Unsure

Did the biological mother use any substances or alcohol during her pregnancy? *

Yes
No
Unsure

Infancy

Was your child an easy baby? *

Yes
No
Unsure

Did your child have sleep problems?

Yes
No
Unsure

Did your child have feeding problems? *

Yes
No
Unsure

Did your child have any medical problems as a newborn or infant? *

Yes
No
Unsure

Later Infancy, Childhood, and Adolescence

Motor Development

Did your child have delays in sitting, walking, feeding themselves with a spoon, or writing letters/numbers? *

Yes
No
Unsure

Please Describe

Language Development

Did your child have delays in talking or require intervention for speech or language problems?

Yes
No
Unsure

Please Describe

Is there any history of stutter or other speech impediment? *

Yes
No
Unsure

Please describe the issue and describe for how long.

Are any other languages spoken in the home? *

Please list the language(s):

Toilet Training

At what age was your child toilet trained? *

Were there difficulties or concerns around toilet training? *

Yes
No
Unknown/Not Applicable

At what age did your child stop bed-wetting (or needing pull-up diapers at night)? *

Does your child/adolescent have any history of bed-wetting or soiling himself or herself after toilet training had been achieved? *

Yes
No
Unsure

Sleep Issues

At what time does your child typically fall asleep at night? *

At what time does your child typically get up in the morning? *

Does your child have difficulty falling asleep or staying asleep at night? *

Do you have problems getting your child to go to bed at night? *

Does your child go to sleep in his/her own bed and stay there all night? *

Does he/she feel rested in the morning? *

Any history of frequent nightmares or sleepwalking? *

Does your child snore or gasp for air at night? *

Please use the space below to address additional sleep concerns

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Previous Evaluations

Please provide copies of results of any previous testing.

Has the child ever been diagnosed by a professional as having any of the problems below. Choose all that apply:

ADHD
Speech/ Language problems
Developmental problems
Emotional/ behavioral problems
Psychiatric hospitalizations
Sensory-Integration problems
Neurological problems
Learning disabilities
Psychiatric diagnosis

If yes to any of the above, please explain below

Emotional Regulation/ Self-Regulation

Does your child have a history of temper tantrums? *

Has your child been physically aggressive towards siblings, parents, peers, others? *

Does your child often over-react emotionally? *

Has anyone expressed a concern about hyperactivity in your child? *

Is your child prone to be impulsive? *

Does your child have difficulty with transitions? *

Does your child have difficulty stopping problematic behaviors when requested? *

Has your child’s school ever reported behavioral or disciplinary issues at school? *

Sensory Integration

Does your child show sensitivity to the sensation of clothing, light, taste, smell, noise, or environments in which there is a great deal of activity? *

Please use the space below to address any additional emotional or sensory issues *

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Social Development

As a preschooler, did your child seem shy? *

As a preschooler, did your child having difficulty separating from a parent? *

Does your child have difficulty joining in social groups? *

Is he/she slow to warm up to other children in group settings? *

Is your child more comfortable interacting with adults than other children? *

Does your child tend to play with younger children? *

Does your child tend to notice and conform to group norms *

Does your child have friends with whom he/she plays regularly? *

Does your child tend to have fights or arguments with friends? *

Has your child ever experienced problems with bullying other children? *

Has your child ever experienced problems with being bullied by other children? *

Please use the space below to address any additional social concerns

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Educational History

In addition to completing this section, please provide school records (report cards, teacher comments, meeting
notes, results of standardized tests) from as far back as you are able and continuing to the present.

Preschool/ Kindergarten

Did your child attend preschool? *

At what age?

How many days per week?

How many hours per day?

Did your child have any problems in preschool? *

Please explain

Does this child currently attend kindergarten? *

Is your child having any problems?

Please list the name of your child's elementary school and how many grades they completed :

Please list the name of your child's middle school and how many grades they completed :

Please list the name of your child's high school and how many grades they completed:

Which subjects or classes does your child find easiest in school?

Which subjects does he/she enjoy the most?

Which subject is most difficult for your child?

Does your child like school?

What is your child’s grade point average?

Did your child repeat a grade?

Attention and Learning Issues

Did you have accommodations (special assistance)? (504 or IEP?)

Did you have problems with behavior while in school?

Does your child receive, or has he/she ever received any special education services?

Does your child receive, or has he/she ever received any early Intervention services?

What accommodations does your child receive in school, if any?

Has your child expressed concern about possible learning issues in the following areas? (Choose all that apply)

Reading
Written Expression
Math
Attention
Handwriting
Spelling
Following Directions
Forgetfulness
Organization
Auditory Reception (Listening)
Verbal Expression

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Psychiatric and General Medical History

Approximate date of your child's last physical *

Child's Height *

Child's current weight *

Child's heaviest weight *

Please list all previous medical problems:

Allergies

Is your child allergic to any medications? *

Please list the medications and type of reactions:

Does your child have any other allergies? *

Please list their allergies and reactions:

Physical Activity/Eating Habits

In a typical week, how often does your child exercise? *

What forms of exercise? *

Does your child overeat sweets or junk food? *

Is there a history of obesity and/or diabetes in the family? *

Has your child/adolescent ever used drugs to your knowledge? *

Please Discuss:

Does your child drink any of the following regularly? (Choose all that appy)

Energy Drinks
Tea
Coffee
Soda

How often and how many energy drinks?

How often and how much tea?

How often and how much coffee?

How often and how many sodas?

Do you have concerns that your child has an addiction to electronics or video games? *

Please Discuss:

Current Medications

List all current medications, including prescription, over-the-counter, supplements, and herbal remedies. Please include the name of the medication, the dosage, and the frequency.

Past Psychiatric Medications

List any previous medications your child has taken for mental, emotional, or behavioral issues. Please include the medication, dosage, frequency, reason for taking the medicine, whether it was effective, negative side effects, and why you stopped taking the medicine.

Medical Problems

Have you or a family member experienced the following problems?

High Blood Pressure

Child
Family Member

Known heart condition

Child
Family Member

Cardiac arrhythmia

Child
Family Member

Heart palpitations (fast, strong, or irregular heart beat)

Child
Family Member

Enlarged heart

Child
Family Member

Dizziness or vertigo

Child
Family Member

Heart murmurs

Child
Family Member

Passing out

Child
Family Member

Shortness of breath with exercise, greater than others with a similar fitness status

Child
Family Member

Family history of sudden unexplained death, sudden infant death syndrome, drowning, or unexplained motor vehicle accidents *

General Medical

Have you or a family member experienced the following problems?

Head trauma or a brain injury

Child
Family Member

Migraines or other headaches

Child
Family Member

Seizures

Child
Family Member

Tics

Child
Family Member

Vision problems

Child
Family Member

Hearing problems

Child
Family Member

Diabetes

Child – Type 1
Child – Type 2
Child – Gestational
Family Member – Type 1
Family Member – Type 2
Family Member – Gestational

Asthma

Child
Family Member

Reflux

Child
Family Member

Chronic constipation, diarrhea, or digestive problems

Child
Family Member

Sleep apnea

Child
Family Member

Thyroid problems

Child
Family Member

Autoimmune disorder

Child
Family Member

Please list all past and current problems not noted above:

Past Surgeries

Please list past surgeries and the date of the operation:

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Psychiatric History

Attention-Deficit/Hyperactivity Disorder (ADHD) or Attention Deficit Disorder (ADD):

Child
Family Member

Oppositional Defiant Disorder (ODD) or Conduct Disorder:

Child
Family Member

Specific Learning Disorder (e.g. Reading, Written Expression, Math):

Child
Family Member

Developmental Delay or Intellectual Disability:

Child
Family Member

Autism Spectrum Disorder (Autism, Asperger’s):

Child
Family Member

Communication or Speech Disorder:

Child
Family Member

Depression (Major Depressive Disorder):

Child
Family Member

Bipolar Disorder (previously known as Manic Depression):

Child
Family Member

Generalized Anxiety, Social Anxiety, or Panic Attacks:

Child
Family Member

Posttraumatic Stress Disorder (PTSD):

Child
Family Member

Panic Disorder:

Child
Family Member

Delusional Disorder:

Child
Family Member

Experienced abuse, neglect, domestic violence, or other trauma:

Child
Family Member

Obsessive Compulsive Disorder (OCD), Skin Picking, Hair Pulling, or Hoarding:

Child
Family Member

Eating Disorder (including Anorexia, Bulimia, Binge Eating, compulsive eating):

Child
Family Member

Schizophrenia / Psychosis, including auditory or visual hallucinations:

Child
Family Member

Substance Abuse:

Child
Family Member

Violence or aggression toward others, or anger problems:

Child
Family Member

Access to firearms:

Child
Family Member (Only if they are a danger to themselves or others because of this fact -do not include lawful ownership)

Legal Problems:

Child
Family Member

Parents/Guardians with children 10 and older -> Please have your child answer the following questions:

In the past few weeks, have you wished you were dead?

In the past few weeks, have you felt that you or your family would be better off if you were dead?

In the past week, have you been having thoughts about killing yourself?

Have you ever tried to kill yourself?

How, when, and why?

Are you having thoughts of killing yourself right now?

Please describe:

Current/Past Psychological and Psychiatric Evaluations and Treatment

Has your child ever been admitted to an inpatient psychiatric facility? *

My child has had previous psychoeducational, psychological, or neuropsychological testing. *

Starting with the most recent, list all prior mental health evaluations and treatment. Please include year, name of provider, and the type of treatment recieved.

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Care Team

Please list all clinicians involved in your child’s care. Include the name of the physician, their location or city, their phone number, and their speciality.

Please use the space below to discuss your child's strengths, hobbies, and interests

Please use the space provided below to discuss any concerns that you feel are important for us to know that have not been covered in the preceding questions. This could include events in your child’s life, e.g. separations, divorce, loss, death, frightening experiences etc. that you think might have impacted his/her development and current level of functioning

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Child and Adolescent Intake Form

Patient Information

Parent/Guardian #1

Parent/Guardian #2

Living Arrangements

Current Family

Presenting Concerns

Developmental History

Prenatal History

Infancy

Later Infancy, Childhood, and Adolescence

Motor Development

Language Development

Toilet Training

Sleep Issues

Previous Evaluations

Please provide copies of results of any previous testing.

Emotional Regulation/ Self-Regulation

Sensory Integration

Social Development

Educational History

In addition to completing this section, please provide school records (report cards, teacher comments, meeting notes, results of standardized tests) from as far back as you are able and continuing to the present.

Preschool/ Kindergarten

Attention and Learning Issues

Psychiatric and General Medical History

Allergies

Physical Activity/Eating Habits

Current Medications

Past Psychiatric Medications

Medical Problems

Have you or a family member experienced the following problems?

General Medical

Have you or a family member experienced the following problems?

Past Surgeries

Psychiatric History

Parents/Guardians with children 10 and older -> Please have your child answer the following questions:

Current/Past Psychological and Psychiatric Evaluations and Treatment

Care Team

In addition to completing this section, please provide school records (report cards, teacher comments, meeting
notes, results of standardized tests) from as far back as you are able and continuing to the present.