Intake Form

Full Name*
First Last
Preferred Name
First
Gender*
- Male
- Female
Date of Birth*
MM slash DD slash YYYY
Place of Birth
Person Completing this Form*
First Last
Relationship to Child*
Phone*
Primary Doctor
Doctor's Phone Number
Mother's Name
First Last
Mother's Place of Employment
Mother's Address
Street Address Address Line 2 City State ZIP Code
Mother's Email
Father's Name
First Last
Father's Place of Employment
Father's Address (if different from mother's)
Street Address Address Line 2 City State ZIP Code
Father's Email
Insurance Provider*
Member ID*
Name of Insured*
First Last
Insured's Date of Birth*
MM slash DD slash YYYY
Child Lives With (Select One):*
- Birth Parents
- Adoptive Parents
- Foster Parents
- Parent and Step-Parent
- One Parent
Other children in the family:
Please list children by name and provide their age, sex, grade and whether there is a history of speech or hearing problems.
Child's Race/Ethnic Group:
- Caucasian, Non-Hispanic
- Hispanic
- African-American
- Native American
- Asian or Pacific Islander
Is there a language other than English spoken in the home?
- Yes
- No
If yes, what language?
Does the child speak the language?
- Yes
- No
Who can we thank for telling you about our practice?
First Last
Do you want a copy of our report sent to the doctor listed above?
- Yes
- No
To what other professional persons or agencies do you want a report sent to?
Pregnancy and Birth History
Was the pregnancy with this child planned?
- Yes
- No
Month of pregnancy when started prenatal care
Mother's age during pregnancy
Which pregnancy was this for the mother (1st, 2nd, etc…)?
Mother's health during pregnancy
- Good
- Fair
- Poor
Did mother drink alcohol during pregnancy?
- Yes
- No
If yes, what type of alcohol and how often?
Did mother use any drugs during pregnancy?
- Yes
- No
If yes, what kind of drugs and how often?
Did mother smoke cigarettes during pregnancy?
- Yes
- No
If yes, how often and how many packs a day?
Did mother take any prescribed medications or vitamins during her pregnancy?
- Yes
- No
If yes, please explain:
How much weight did mother gain during pregnancy?
Did mother have any complications during the pregnancy?
- Yes
- No
If yes, please explain:
List all pregnancies of the biological mother (include year, length of pregnancy, birth weight, difficulties during pregnancy, difficulties at birth and whether or not the child is living)
Where was the child born?
Name of Hospital
Location of Hospital
City State
Length of Pregnancy
Length of Labor
Labor was:
- Normal
- Difficult
Please Explain:
Type of Delivery:
Baby's position:
- Head down (vertex)
- Legs or bottom down (breech)
Baby's Apgar scores, if known:
Were there any problems during labor and/or delivery?
- Yes
- No
Please explain:
Birth Weight:
Birth Length:
Birth Head Circumference:
Duration of Mother's Hospital Stay and Duration of Baby's Hospital Stay?
Were there any problems with mother or baby when in the hospital?
- Yes
- No
Please explain:
Baby passed newborn hearing screening?*
- Yes
- No
Was baby breast fed, bottle fed, and/or tube fed? At what age was each method completed?
Any hospitalizations since birth?*
- Yes
- No
Please explain:
Any operations since birth?*
- Yes
- No
Please explain:
Over the past 12 months, child's general health has been:*
- Good
- Fair
- Poor
Over the past 12 months, have you noticed any worsening of your child's health?
- Yes
- No
Please explain:
Do you have any worries about your child's health?
- Yes
- No
Please explain:
Please list any allergies to food or medications:*
Please type ‘not applicable’ if there are none.
Child's Health History
If your child has had any of the following, please check and explain when it occurred:
Neurological/musculoskeletal
- Head injuries
- Dizzy spells
- Seizures or epilepsy
- Frequent Headaches
- Poor coordination
- Weakness
- Speech defects
- Meningitis or encephalitis
- Loss of consciousness, coma, fainting
- Sudden episodes of staring, confusion, altered awareness or responsiveness
- Excessive fatigue or daytime sleepiness
- Unusual movements (tremors, shaking, jerking, tics)
- Unusual walk or balance
- Frequent stuttering or stammering
If you marked any of the above boxes, please explain:
Hearing
- Ear infections
- Ear tubes
- Hearing problems
If you marked any of the above boxes, please explain:
Date of most recent hearing exam, if applicable:
MM slash DD slash YYYY
Results of most recent hearing exam, if applicable:
Vision
- Vision problems
- Wears glasses and/or contacts
- Eyes turning in or out
If you marked any of the above boxes, please explain:
Date of most recent vision exam, if applicable:
MM slash DD slash YYYY
Results of most recent vision exam, if applicable:
Respiratory
- Frequent colds
- Asthma
- Sinus condition
- Chronic cough
- Hay fever
- Constant nighttime snoring or difficulty breathing
If you marked any of the above boxes, please explain:
Cardiovascular/Hematologic
- Heart murmur
- Heart disease
- Anemia (low blood count)
If you marked any of the above boxes, please explain:
Gastrointestinal
- Frequent diarrhea
- Constipation
- Excessive vomiting or dehydration
- Frequent stomach pains
If you marked any of the above boxes, please explain:
Genitourinary
- Urination in pants/bed
- Excessive urination
- Pain while urinating
- Unusual or strong odor to urine
If you marked any of the above boxes, please explain:
Growth/Nutrition
- Excessive weight gain
- Slow height gain
- Slow weight gain
- Difficulty feeding, chewing or swallowing
If you marked any of the above boxes, please explain:
Skin
- Severe, frequent or unusual skin problems or rashes
- Birthmarks (light, dark or red skin patches that were present at birth or developed later)
If you marked any of the above boxes, please explain:
Sleep
- Difficulty falling or staying asleep
- Experience nightmares, night terrors, sleep walking, sleep talking
If you marked any of the above boxes, please explain:
Other
- History of sexual abuse
- History of physical abuse
- Suspicion of alcohol or drug abuse
If you marked any of the above boxes, please explain:
Has this child ever had or is he/she currently receiving any type of professional mental health treatments? (e.g. psychotherapy, family counseling, etc.)
- Yes
- No
Please explain:
What medications is your child taking at this time?*
Please list the name of medication, dosage, frequency, and any other information. Please type “not applicable” if there are none.
Has your child ever had a reaction to any medications?*
- Yes
- No
Please explain:*
Are the child's immunizations up to date?*
- Yes
- No
If not, please explain:*
Family History
Are the birth mother and father related in any way? (1st cousins, 2nd cousins, etc.)
- Yes
- No
Please explain:
Does anyone in the family have any of the following conditions? Check all that apply, past or present.
Anyone in the family refers to the child’s mother, father, sibling, mother’s family, or father’s family.
- Mental retardation
- Learning disorder
- Did not graduate from high school
- Aggressive or violent
- Attention problems; hyperactivity
- Depression
- Suicide attempts
- Anxiety disorder/panic attacks
- Psychosis or schizophrenia
- Obsessive-Compulsive Disorder
- Alcohol or drug abuse
- Trouble with the law; arrested, incarcerated
- Physical abuse
- Sexual abuse
- Tics or Tourette Syndrome
- Behavior problems as a child
- Seizures
- Autism
- Birth defects or familial disorder
- Cerebral Palsy
- Hearing problem; deafness
- Vision problem; blindness
You selected "Mental Retardation" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Learning Disorder" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Did not graduate from high school" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Aggressive or violent" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Attention problems; hyperactivity" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Depression" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Suicide attempts" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Anxiety disorder/panic attacks" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Psychosis or Schizophrenia" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Obsessive-Compulsive Disorder" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Alcohol or drug abuse" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Trouble with the law; arrested, incarcerated" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Physical abuse" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Sexual abuse" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Tics or Tourette Syndrome" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Behavior problems as a child" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Seizures" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Autism" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Birth defects or familial disorder" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Cerebral Palsy" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Hearing problem; deafness" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
You selected "Vision problem; blindness" above, please select all of the family members that this applies to:
- Mother
- Father
- Sibling
- Mother’s Family
- Father’s Family
Any other significant family history the therapist should be aware of?
- Yes
- No
Please explain:
School History
What school/daycare does your child attend?*
Teacher's name
What grade is he/she in?
Type of classroom:
- Regular
- Special Education
Number of children in the class:
Has your child ever skipped or repeated a grade?
- Yes
- No
Please explain:
Does your child receive therapy services (ST, OT, PT) at school?*
- Yes
- No
Does your child have an IEP or 504 plan?*
- Yes
- No
What are your child's strengths and/or best subjects?
Is your child having difficulty with any subjects?
Is your child receiving help or tutoring in any subjects?
What activities does your child like to engage in? What do they like to play with? What motivates this child?
What type of discipline do you use at home?
Is there any other information regarding your child that you would like to share with Jubilee Therapy?

Pregnancy and Birth History

Child's Health History

Family History

School History