WELL MINDS COUNSELING, PLLCTana Carpita, MSW, LICSW2525 E. Arizona Biltmore Circle, Suite B220Phoenix, Arizona 85016(425) 588.9280 Please enable JavaScript in your browser to complete this form.Client's Name *FirstLastDate of Birth:Date of Intake:AgeGradeClient prefers to be called/nickname:Client’s preferred Gender and Pronouns:Client’s ethnic and cultural identity:Name of Person Completing Intake Form: *FirstLastRelationship to Client: Home Address:Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMailing Address: (if different)Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhone (Main/Primary):May I Leave a Message?YesNoOther Phone:May I Leave a Message? YesNoInsurance Coverage/Company: If not applicable, you are:Private PayOut of NetworkWho does client live with? (List name, relationship, and age.)If primary caregivers/parents are divorced or separated, who has legal custody and medical decision rights of the child? (List name and relationship.)(In the case of joint custody following divorce, all parents/guardians with legal custody or medical decision making rights must sign forms consenting to the counseling.) Is there a parenting plan in place? NoYesIf yes, please provide a copy. Click or drag a file to this area to upload. Is this child adopted or a foster child? YesNoIf adopted, does child know of adoption?YesNoN/AWhat age was your child at the time of the adoption?Other relevant information about adoption process, birth family, etc.:What is life like at home? Environment, challenges, what is going well? Tell me about your concerns and expectations Reason for coming to therapy/counseling now: Are your child’s problems affecting any of the following? Handling everyday tasksHygieneWork/School FinancesSelf-esteemHealthHousingRelationshipsRecreational activities Legal matters OtherIf Other:What do you hope to achieve through this counseling experience? (Goals? What will be different after working in therapy?) If client is not completing this form, what does the child/youth (client) hope to get out of this experience? (Goals; What will be different after ending therapy?) Medical/Well-being History: Name of Primary Care Doctor/Clinic:Current Medical Conditions for which your child is currently being treated: Biological/Family History: Mental health, Neurological, Developmental, Learning Diagnoses in Family members:Client’s Current Medications (include prescribed, naturopathic, supplements) | List Name of medication, dose, when started, and reason for taking.Has the client/your child ever experienced any of the following medical conditions? N/AAsthmaObesityMeningitisDiabetesFrequent Headaches Skin ConditionSeizures/Epilepsy Hearing problems Stomach achesHead injury Vision problemsFreq. Ear infectionsChronic painDizziness/fainting High fevers Autoimmune disorder High blood pressureThyroid ConditionAnemiaOtherIf yes, is this currently (within the last month) bothering your child? How? SLEEP: Regarding sleep, does your child have any difficulty:N/Afalling asleepwaking up in the AMstaying asleep throughout the nightOther concerns about sleep, fatigue, daytime sleepiness, naps, quality or quantity of sleep? APPETITE/DIET: Do you have any concerns about your child’s appetite (not feeling hungry, skipping meals, over-eating/eating when not hungry, etc.), or any concerns about your child’s diet/foods they eat? Intervention/Counseling History:CheckboxesNoneHas your child ever been given a mental health diagnosis?NoYesIf so, what?Has the youth/child attended counseling before?UnsureNoYes If yes, where/with whom?Reason/Initial concern for seeking counseling previously:Were the primary reasons for seeking counseling in the past resolved to your satisfaction at the time counseling ended? (Please explain):Please list/describe any other treatments/interventions the client has participated in to address primary concerns for seeking counseling now (i.e., Psychiatrist, medication, Groups, Pastor, Occupational Therapy, School Counselor, ABA/Behavioral, Vision therapy, etc.) List type of treatment, when, provider, and reason for treatment. School Information School InformationPublic SchoolPrivate SchoolCollege/UniversityHome-Schooled/Co-Op Name of School Client Attends:City:Current Grade Level:Current Teacher’s Name:Does your child receive any Special Education services?NoYesIf yes, reason: If yes, does your child have:IEP504 PlanOtherIf other: Does your child receive any formal support services or interventions at school? NONESpeech Therapy Resource RoomSocial SkillsOccupational TherapyOtherIf other:Has your child had any of the following difficulties at school? SuspensionReferrals or detentionsSpeech problems Incomplete homeworkPoor gradesAttendance problemsLearning problemsTeased or picked on Gang influenceAny other concerns about your child’s performance or behavior at school that you would like addressed in therapy? What is school life like for child?Safety and Client Legal History:CheckboxesNoneAre there any other agencies required/mandated to be involved with the family (DSHS, Child Protective Services, Courts, etc.)?NoYesHas the minor ever been charged or convicted of a sexual offense against another Minor?NoYesHas your child ever made statements about, or attempted to hurt him/herself, including suicidal ideation? UnsureNoYesIf yes, please describe: Has your child ever had made statements about planning to hurt, or made attempts to hurt, someone else?UnsureNoYesIf yes, please describe:Strengths, Special Interests, Other needs: Please describe your child’s and family’s strengths, skills, and talents: Describe any special areas of interest or hobbies (art, books, animals, physical fitness, etc.):If not already addressed, please comment on, or describe, what information would be most helpful for this therapist to know in order to be of the most help to the client/you/the family? What qualities in a therapist are important to your child/you/family?Submit
