CHILD AND ADOLESCENT INTAKE QUESTIONNAIRE - …

1 CHILD AND ADOLESCENT INTAKE QUESTIONNAIRE - PARENT FORM CHILD S NAME _____ Date_____ First Middle Last Birthdate _____ Current Age _____ Month Day Year Years / Months Address _____ Phone Numbers _____ _____ _____ Home Mother s Cell Father s Cell CURRENT SCHOOL _____ _____ Address _____ Phone Number _____ _____ Main Teacher Principal Grade _____ Type of Class (Regular, EH, ED, Resource, GATE, etc.)

Please include the disorder, relationship of the individual to your child, any treatment that person has received, and the results of any treatment. Has any family member ever taken any psychiatric or mental health medication?

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  Questionnaire, Child, Disorders, Intake, Adolescent, Child and adolescent intake questionnaire

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