EBHS Adolescent Intake Form - Effect Behavioral Health Solutions

Adolescent Name *

First

Last

Date of Birth *

Parent/Guardian Name *

First

Last

Parent/Guardian Email *

Parent/Guardian Phone *

Emergency Contact Phone

School Name *

Grade Level *

Current Grades/Status *

Parent/Guardian stressful noticed

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number (if applicable)

Email (if applicable)

Primary Concern / Reason for Intake *

Relevant Medical History / Medications *

Current Symptoms / Behaviors (optional) *

What concerns led you to seek therapy for your child? *

When did these concerns begin?

What changes have you noticed in your teen's behavior? *

Has anything stressful or traumatic happened recently?

Who lives in the home?

How would you describe family relationships?

Has the teen experienced divorce or family conflict?

Yes
No
Not sure

Any major family changes recently (move, death, separation)?

Primary care physician name and contact

Any history of hospitalizations?

Yes
No
Not sure

Has the adolescent previously received counseling or therapy?

Yes
No
Not sure

If yes please desribe. (copy)

Any past psychiatric hospitalizations?

Yes
No

If yes please desribe.

Any past psychiatric hospitalizations?

Yes
No

If yes please describe

Has the adolescent experienced any traumatic events?

Yes
No
Not sure

If yes please describe

History of abuse (select all that apply)

If yes please describe

Exposure to domestic violence

Yes
No
Not sure
Prefer not to say

If yes please describe

Consent (Parent/Guardian)

I confirm I am the parent/guardian and consent to this intake.
I understand this form is for intake purposes and does not replace emergency services.
I agree to be contacted about next steps and scheduling.
I confirm the information provided is accurate to the best of my knowledge.