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Minor Therapy Intake Form
Child’s Information
First Name
Last Name
Birthday
Parent/Guardian’s Details
First Name
Last Name
Email
Phone
Presenting Problem
What Is Going On?
Duration
How Long Has This Been Going?
Frequency
Has This Occurred Before?
Prior Interventions
Has the child been helped before?
Yes
No
If yes, list previous professional(s) seen, describe treatment
Aggravating Factors
What makes things worse?
Relieving Factors
What makes things better?
Current Symptoms
How are you feeling now? (Check all that apply)
Anxiety
Appetite Issues
Avoidance
Depression
Fatigue
Hallucinations
Irritability
Loss of Interest
Racing Thoughts
Sleep Changes
Crying Spells
Excessive Energy
Guilt
Impulsivity
Panic Attacks
Risky Activity
Suspiciousness
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