Adolescent Mental Health Intake Form
Personal Information
First Name
Last Name
Date of Birth
Age
Gender
Female
Male
Non-binary
Prefer not to say
Address
Parent/Guardian Name
Relationship
Parent/Guardian Phone
Parent/Guardian Email
Current Concerns
Reason for Seeking Help
How long have these concerns been present?
Describe any symptoms (e.g., mood, sleep, eating, behavior changes)
Mental Health & Medical History
Previous mental health treatment (therapy, medication, hospitalization, etc.)
Any previous diagnosis?
Current or past medical issues
Current medications
Family & Social Information
Family composition (parents, siblings, others at home)
School and grade
Academic performance/concerns
Friendships and social supports
Safety & Risk
Any concerns about safety (self-harm, suicidal thoughts, harm to others)?
Other important information