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» Provider Directory » Find a Therapist » New York » Lynbrook Therapists » Therapist Profile

 

Lois Plitt Warren, MPS, ATR-BC, LCAT

Intake Form - Minor

Intake Form - Minor

Completed by parent/guardian- Please print. Use additional paper, if needed

Your answers will help to facilitate an effective beginning of the therapeutic relationship. Please attach copies of recent assessments by other mental health professionals ,physicians, and schools.

Thank you for answering some difficult questions as honestly as possible. Lois

*If you would like to save paper, I recommend copying and pasting this form into a Word document and printing it out from there. Thank you.

 

Name of Minor ______________________________Birth Date____________

 

Address_________________________________________________________

 

Parentís/Guardianís Names (1) _________________ (2) ___________________

 

Home Phone __________________ E-Mail _______________________

 

(1) Work Phone________________ Cell Phone____________________

 

(2) Work Phone________________ Cell Phone____________________

 

Parentís Marital/Relationship Status_____________________________

 

Members of Family /Household:

Name Age RelationshipLocation of residence

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Grade _____________School________________________________________

 

School Psychologist___________________ phone________________________

 

Primary Care Physician:

Name________________________________________________________

 

Address________________________________________________________

 

Phone________________________________________________________

Initial___________

 

 

Present medical conditions, allergies, prescription and O-T-C medication______

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

________________________________________________________________

 

In treatment with other mental health professionals:

 

Name_________________________________Profession________________

 

Address _________________________________________________________

Phone___________________________Period of treatment_______________

 

Diagnosis________________________________________________________

 

Medication ______________________________ Dosage__________________

 

Name __________________________________Profession________________

 

Address _________________________________________________________

 

Phone___________________________Period of treatment______________

 

Diagnosis________________________________________________________

 

Medication ______________________________Dosage_________________

 

Referred by:

Name___________________________________________________________

Address _________________________________________________________

 

Phone___________________________________________________________

 

Email ___________________________________________________________

 

Insurance Company:

____________________________________________Phone_______________

 

Insuredís name________________________ ID#_________________________

 

Clientís ID#_______________________________________________________

 

-2-initial______

 

 

Please use additional paper when necessary.

 

Developmental milestones: To the best of your ability, describe any problems relating to birth, eating, sleeping, walking, communication, socialization, learning, and fine and gross motor coordination _________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

 

Current primary symptoms or complaints_______________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

 

Dates and conditions surrounding first appearance of each symptom__________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

________________________________________________________________

 

________________________________________________________________

 

-3-initial ______

 

Other history of medical or psychiatric problems (include age of onset)________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Socialization issues_________________________________________________

 

________________________________________________________________

 

________________________________________________________________________

 

Problems in school (supply copy of I.E.P, if applicable) ____________________

 

________________________________________________________________

 

________________________________________________________________

 

Other recent stressors or pressures__________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Support system ___________________________________________________

 

________________________________________________________________

 

_______________________________________________________________

 

Problems with eating, use of stressful foods and substances, and frequency of use (caffeine in coffee, tea, chocolate, soda; sugar; alcohol; drugs; tobacco)

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Sleep habits______________________________________________________

 

________________________________________________________________

 

-4-initial______

 

 

Physical activity____________________________________________________

 

________________________________________________________________

 

Creative activity____________________________________________________

 

________________________________________________________________

 

Relaxation techniques practiced______________________________________

 

Special interests, skills, hobbies______________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Personal strengths_________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Has your child ever expressed or acted upon any suicidal thoughts? _________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Goals for art therapy_______________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

-5-initial ______

 

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Why art therapy___________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

Other concerns or information________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

________________________________________________________________

 

You may feel quite stressful after completing this form. If you would like to release some of this stress, spontaneously draw any image you desire in the space below. Do not aim for "perfectĒ artwork. More paper may be needed.

 

 

 

 

 

 


 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print name of parent/guardian completing form___________________________

 

Signature_________________________________________ Date___________

 

 

 


Lois Plitt Warren, MPS, ATR-BC, LCAT, Lynbrook

 Office Locations
Lynbrook, NY 11563
Great Neck, NY 11021

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Last Modified: 1/23/2019  


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