Psychological Services Intake Form Parent or Guardian's First Name* Parent or Guardian's Last Name* Phone Number*Email Address* Child's Name* What led you to seek psychological services for your child and/or family?Has your child ever been evaluated or treated by a psychologist or psychiatrist in the past? Yes No If yes, when and for what reason(s)? Indicate which stressors your child is experiencing now (within last 6 months).Indicate which stressors your child is experiencing now (within last 6 months). Death of family member Personal injury/illness Conflicts within family Academic difficulties Sexual abuse Illness of family member Parents separated Conflicts with friends Change in residence Physical abuse Illness of friend Parents divorced Conflicts at school Legal problems Verbal/emotional abuse Indicate which stressors your child is has experienced in the past.Indicate which stressors your child is has experienced in the past. Death of family member Personal injury/illness Conflicts within family Academic difficulties Sexual abuse Illness of family member Parents separated Conflicts with friends Change in residence Physical abuse Illness of friend Parents divorced Conflicts at school Legal problems Verbal/emotional abuse Other Concerns:Please check all that apply to your child. Suicidal thoughts Depression/sadness Anxiety/nervousness Recurrent/intrusive thoughts Nightmares Academic difficulties Loss of appetite or over-eating Weight loss or gain Recurrent/intrusive disturbing recollections or dreams Overwhelming need to perform certain behaviors/rituals Excessive fears or phobias Significant concerns with physical problems Difficulty sleeping Poor frustration tolerance Explosive anger Fatigue Rapid mood changes Loss of interest in almost all activities Feeling worthless Racing thoughts Feelings of hopelessness Decreased need for sleep Destroys other people’s property Irritable Is cruel to animals Starts fights with others Homicidal thoughts Poor self esteem Aggressive Visual or auditory hallucinations Stomach aches Unmotivated Bizarre behavior Overly dependent Shy and withdrawn Quiet Harms self on purpose Resists change Self-stimulates Wets bed or clothes Exhibits sexually inappropriate behavior Picks at skin or pulls out hair Overly emotional Immature for age Is very fidgety Can’t remain seated Can’t wait his/her turn when playing with others Answers before s/he hears the whole question Rarely follows other’s instructions Easily lies to others Steals things Please describe any additional unusual behavior. What are your goals for evaluation and/or therapy?What are 3 positive qualities about your child?