Adolescent Social Anxiety Assessment Intake Form
Personal Information
Full Name
Date of Birth
Age
Gender
Female
Male
Non-binary
Other
Prefer not to say
Grade/Year
Parent/Guardian Name
Contact Number
Referral Information
Referred By
Reason for Referral
Social Anxiety Concerns
Describe social situations that are difficult or cause anxiety
When were these difficulties first noticed?
How often do these feelings occur?
Daily
Weekly
Monthly
Occasionally
Specific situations that are particularly stressful
How does this impact daily life (school, friends, activities)?
Coping & Support
Strategies used to cope
Who provides support/help?
Other Relevant Medical or Family History
Relevant physical or mental health history
Family history of anxiety or related conditions
Additional Notes