Cynthia M Chase

CYNTHIA M CHASE

34 Connolly Drive

Old Saybrook, CT 06475

860-395-0284

Child and Adolescent intake form

The following forms may be sent to me at cynthia_chase@sbcglobal.net or brought with you on your first appointment.  Here’s how to do it:  go to edit, select all, copy, then go to send a new email at cynthia_chase@sbcglobal.net, then paste. Fill in the data, and send email back to me.  I recommend that you send it along first so that we may get started right away at your initial appointment!

Today’s Date:

Parents or Guardians:  Please fill out one form per child; this information is private and confidential, as are all of our sessions.  Please complete this form as completely as you can.

Patient’s name:

Male or female:

Date of Birth:

City and State where born:

Name/s of custodial parent/s or step-parent:

Custodial parent’s home address:

Street address:

City and State

Zip code

E-mail address of parent/s

Home telephone number/s:

Work phone number/s:

Cell phone/s:

Occupation for each parent/custodian/stepparent:

Non-custodial/or other parent’s or step-parent’s home address:

Street address:

City and State:

Zip code

E-mail addresses/s

Home phone number:

Work phone number/s:

Cell phone number/s:

Occupation/s:

Parent’s status:  (Please circle) single, married, separated, divorced, widow (er), live-in partner

Child’s Siblings/Half-siblings/Step-siblings (name, age and home address):

Patient’s Medical Doctor (name and phone number):

Responsible Party billing address:

Street Address:

City and State:

Zip Code:

E-mail address:

Home phone number:

Work phone number:

Cell phone number:

Responsible Party Insurance Company:

Insurance Company phone number:

Insurance Company address:

Patient’s relationship to the insured:

Insured ID number:

Insured DOB:

Policy/Group number:

Date coverage initiated:

Deductible:

Co-Pay:

Occupation:

Employer:

Employer Address:

Emergency Contact name and phone number:

Referral Source:

Patient’s Residence (please circle):  Biological parent’s home, relative’s home, foster home, adoptive home.

Full Term (please circle):  Yes     No

Complications at birth:

Family Structure when baby was born:

Milestones (please indicate age):

Sat up_____Crawled_____Walked_____Talked_____Toilet Trained_____

Describe delays or complications in any of these areas:

Daycare or pre-school:  Yes_____No_____

Comments:

Who was the child’s primary caregiver(s) from birth to 3 years old?

Family History (include births, divorce, losses, transitions, remarriage, illness, moves, etc.):

Any major illness/surgeries:  Yes_____No_____

Please describe ages and illnesses/surgeries:

Has the child ever been ill or on medications (list age and type of illness):

Any psychiatric illness/hospitalizations:  Yes_____No_____Age/s: _____

Any traumatic events/s:  Yes_____No_____

Please describe:

Any involvement with Protective Services/DCF (Age/s):

Any substance use/abuse/dependency:  Yes_____No_____Age/s:

Please list names/amounts:

History of Counseling:  Yes_____No_____

Please circle type of treatment:

• Family
• Individual
• Group
• School
• Alateen
• Day treatment
• Hospital
• Other

Name/s of prior therapist/s and reason for treatment:

May I contact them?

Name/s:

Telephone number/s:

Please list facility/ies and dates:

School/s:

Address:

Grade:

Teacher/s:

Please describe your child/teen’s overall school experiences, including typical grades, socialization, type of classes, i.e. special education, gate, etc:

• Grades 1st to 5^th (name school/s attended):

• Grades 6^th to 8^th:   (name school/s attended):

• Grades 9 and up (name school/s attended):

Describe your child/teen’s challenges:

Describe your child/teen’s temperament:

Describe your child/teen’s success and qualities:

People your child/teen seems to trust and relate well with:

This form was completed by:

Patient signature (if applicable):

Parent signature:

Date:

Parent signature:

Date:

Parent signature:

Date

Parent signature:

Date

(11-09; intake inspired by Claudia Rhodes, LCSW)