Therapy Intake Form

Child Intake Form

Simple version

Step 1 of 10

Today's Date*
MM slash DD slash YYYY
Identification
Child's Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Child's Age*
Please enter a number from 0 to 18.
Foster Care or Adopted*
If in Foster Care or Adopted at what age?
Please enter a number from 0 to 18.
Child's Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of person bringing child to counseling sessions?*
First Last
Relationship to child*
Phone Number*
Is it okay to leave a message?*

Family Information
1. Name of the child’s foster parents or other legal guardians (if applicable)
First Last
2. The name of the child’s biological Mother
First Last
3. The name of the child’s biological Father
First Last
4. Marital Status of biological parents:
5. Who has legal guardianship or custody of your child:
First Last
Please list all individuals presently living in the home with the child:
Father's Name
First Last
Father's Age
How does the child get along with his/her Father?
Father's Grade or Occupation
Step-Father's Name
First Last
Step-Father's Age
Step-Father's Grade or Occupation
How does the child get along with his/her Step-Father?
Mother's Name
First Last
Mother's Age
How does the child get along with his/her Mother?
Mother's Grade or Occupation
Step-Mother's Name
First Last
Step-Mother's Age
How does the child get along with his/her Step-Mother?
Step-Mother's Grade or Occupation
Brother (s)
Please list all Brothers
Step-Brother (s)
Please list all Step-Brothers
Sister (s)
Please list all Sisters
Step-Sister (s)
Please list all Step-Sisters
Grandmother's Name
First Last
Grandmother's Age
How does the child get along with his/her Grandmother?
Grandmother's Occupation
Grandfather's Name
First Last
Grandfather's Age
How does the child get along with his/her Grandfather?
Grandfather's Occupation
List others who are significant to child who live outside the home
What stresses does your family struggle with?*

Children’s Advocacy Center of the Lookout Mountain Judicial Circuit
Certification of Informed Consent and Confidentiality Waiver
The Children’s Advocacy Center is dedicated to providing treatment services to children and families that have experienced trauma related to abuse, or who are involved in a situation in which abuse is suspected. We recognize that effective child abuse intervention requires a cooperative effort between the professionals in many agencies and disciplines. All professionals involved in this effort meet regularly to form a multidisciplinary team that reviews investigations of reported child abuse. The team consists of professionals from the Department of Family and Children Services, Law Enforcement, the District Attorney’s Office, and Children’s Advocacy Center staff.

The team can be considered a vehicle through which we help children and families negotiate the various systems involved in protecting children: The team’s purpose is twofold:

1. To ensure that each child receives the appropriate intervention (required to protect him/ or her from further abuse and/ or traumatization). 2. To make team decision regarding prosecution of the alleged offender.

All information shared within the team meetings is kept strictly confidential among team members.

If your child begins therapy/evaluation while an investigation is still being conducted, there are some further issues about which you should be aware. Often, children tell their history of abuse gradually over a period of time. As a result, your child may reveal more information to his or her therapist/ evaluator than was revealed during the initial investigative interview/ evaluation. In order to ensure appropriate team decisions are made, your therapist/ evaluator will need to inform other team members of any new disclosures that are made in therapy/ evaluation. Also, if the therapist is the first to hear these allegations, she may on occasion, be subpoenaed to testify in court if your child’s case involves court proceedings.

Confidentiality does not legally apply under two conditions:

1. Any information regarding new or different child abuse must be reported to the appropriate agency. 2. Information that the client is in danger of inflicting serious harm upon her/ himself or others (i.e. suicidal or homicidal) will necessitate appropriate protective measures.

Additionally, the law may waive confidentially under the following circumstances:

1. Authorization (by a competent party) to release previously confidential information to include written records; 2. Pursuant to a legally sufficient court subpoena; and 3. In response to a proper court order.

Information shared with the therapist/ evaluator that does not impact the investigation or does not fall into the above two categories will be kept strictly confidential.

If you have any questions regarding our policies on confidentiality, please direct them to your Therapist or Forensic Evaluator. She will be happy to discuss this and any other further concerns with you.

I certify that I have read and understand the policies on confidentiality. I understand the terms of this statement. I am entering myself and/ or my child into treatment/ evaluation by my own free will.
Signature
Consent
I agree to the Certification of Informed Consent and Confidentiality Waiver
Name
First Last
Date
MM slash DD slash YYYY
Children’s Advocacy Center of the Lookout Mountain Judicial Circuit

Consent of Services to Minors
Please read the following before signing:
By signing below, you attest that you have the legal right regarding:
Child's Name
First Last
To seek mental health service, crisis intervention/counseling for this child, and you are not required to obtain permission from any other person.

In cases involving custody, we may require that you provide proof of legal custody.

I hereby authorize the professional staff of The Children’s Advocacy Center of the Lookout Mountain Judicial Circuit to provide crisis intervention, therapy, counseling, and/ or other treatment as deemed necessary for:
Hidden
Untitled
To seek mental health service, crisis intervention/counseling for this child, and you are not required to obtain permission from any other person.

In cases involving custody, we may require that you provide proof of legal custody.

I hereby authorize the professional staff of The Children’s Advocacy Center of the Lookout Mountain Judicial Circuit to provide crisis intervention, therapy, counseling, and/ or other treatment as deemed necessary for:
Child's Name
First Last
I understand that information provided may be shared with collaborating agencies as listed on the MDT release of information form, which I have also signed. I also understand that state and/ or federal laws require some situations to be reported with or without consent (e.g. child abuse, threat to harm self or others). I give permission for a faxed or photocopied signature to serve as the original with regards to this release. I may withdraw consent for services at any time by providing written, signed and dated notice.

Therapy Expectations
Clicking this box acknowledges your Consent of the following statement:*
Therapy is offered through The Children’s Advocacy Center of The Lookout Mountain Judicial Circuit (CAC-LMJC). This is a free therapy service offered through the center. Your insurance will not be billed nor will you be expected to pay out of pocket.
Clicking this box acknowledges your Consent of the following statement:*
Trauma-focused Cognitive Behavioral Therapy is the type of therapy most utilized by this Clinician. However, other therapy modalities such as CBT, child-centered play therapy , etc., may be incorporated at therapist’s discretion depending on the child and his/her individual needs.
Clicking this box acknowledges your Consent of the following statement:*
Therapy will be on a weekly basis unless you’ve been notified by your child’s therapist of an alternate schedule. However, you can typically expect 1 hour each week unless a holiday, illness, or vacation is scheduled.
Clicking this box acknowledges your Consent of the following statement:*
It is imperative that therapy is maintained on a consistent basis for best therapeutic results for the child. You are given a 15-minute grace period. If you should show up after the grace period your appointment will be rescheduled for another date. If you are more than 15 minutes late, the therapist will assume you are not coming. If you must cancel an appointment, you must call the therapist with a 24-hour notice. If there are 3 appointments or two consecutive appointments that are a no-show where the therapist is not given notice, the therapist will assume that you are no longer interested in services. In this case, your child will be put back on the waiting list.
Clicking this box acknowledges your Consent of the following statement:*
The therapy duration is mostly considered short – term. However, each child and situation is unique and will progress at different rates. This therapist will keep you informed on how your child is progressing in therapy so you will have an idea of what to expect.
Clicking this box acknowledges your Consent of the following statement:*
You as the caregiver are a very important part in your child’s recovery. Research shows that caregiver support is one of the most important indicators of healing. I will be meeting with you regularly to update on progress and teach you skills your child is learning so you will know how to reinforce learned skills at home. Caregivers are expected to remain at the center during the child’s therapy session.
Clicking this box acknowledges your Consent of the following statement:*
Therapy is most beneficial when one can generalize skills and work accomplished in session during their daily lives. With this in mind, I do assign short “homework” that I do expect you and your child to accomplish at home outside of the therapy session.
Clicking this box acknowledges your Consent of the following statement:*
I look forward working with your child and you during this process. If you need to contact me, you can reach me at 706-866-8811. If you have an immediate psychiatric emergency, please contact 911.
Clicking this box acknowledges your Consent of the following statement:*
The Children’s Advocacy Center therapist will not make recommendations regarding custody, visitation schedules, or become involved in civil/domestic matters. The Children’s Advocacy Center will take every step to ensure that counseling is therapeutic and unbiased regarding such issues. By signing this form, you agree to avoid making such requests and understand that the Children’s Advocacy Center will not honor such requests.
Signature*
Caregiver Signature*
First Last
Date*
MM slash DD slash YYYY
Post Custom Field
Untitled

Child Intake Form

Step 1 of 10

Identification

Family Information

Please list all individuals presently living in the home with the child:

Birth History:

Education

Please describe any issues related to:

Health Information

Legal Involvement:

Therapy:

Children’s Advocacy Center of the Lookout Mountain Judicial Circuit

Children’s Advocacy Center of the Lookout Mountain Judicial Circuit

Consent of Services to Minors

Therapy Expectations