Adolescent Anxiety Intake Form
Personal Information
Full Name
Date of Birth
Age
School
Grade
Parent/Guardian Name
Parent/Guardian Contact Number
Parent/Guardian Email
Anxiety Symptoms
Describe the anxiety symptoms that the adolescent is experiencing
How long have these symptoms been present?
How often do the symptoms occur?
How intense are the symptoms?
Mild
Moderate
Severe
Are there identifiable triggers?
What coping strategies are currently being used?
How do symptoms impact daily functioning (school, social, home)?
History
Past mental health concerns or treatments
Family history of anxiety or other mental health conditions
Current medications
Additional Information
What are your goals for seeking help?
Questions or concerns