Child and Adolescent Therapy Intake Template
A parent or caregiver shares a child’s concerns, behavior, development, family context, and previous support with a therapist before an initial appointment.
When to use it
- Before a child’s first therapy appointment
- When a therapist is gathering background before an assessment
- When starting with a new child or adolescent therapist
- When a family wants to describe concerns before a consultation
What it asks
- Your name
- Your relationship to the child
- Your email address
- Your phone number
- Child’s name
- Child’s date of birth
- What concerns would you like support with?
- What behaviors or challenges have you noticed at home?
- What behaviors or challenges have you noticed at school?
- Are there developmental, learning, or communication details you’d like us to know?
- Is there anything about your family situation that may help us understand your child’s needs?
- Has your child had previous therapy, assessments, or other support?
Why it should be encrypted
The answers may reveal a child’s mental health, development, school challenges, and family circumstances. Keep them from being readable by outsiders or people who are not involved in the child’s care.
Tips
- Tell parents to share only details that will help the therapist understand the child’s needs.
- Add a note explaining who will review the intake and how to share urgent concerns.
- Customize questions to suit the child’s age and the therapist’s intake process.