Child Counseling Intake Form
Child's Information
* Full Name: _______________________________________
* Date of Birth: ____________________________________
* Age: ___________________________________________
* Gender: ________________________________________
* School: _________________________________________
* Grade: __________________________________________
* Preferred Pronouns: _______________________________
________________


Parent/Guardian Information
* Name(s): ________________________________________
* Relationship to Child: _____________________________
* Phone Number(s): __________________________________
* Email Address: ___________________________________
* Preferred Method of Contact: Phone / Email / Text
________________


Emergency Contact Information (other than parent/guardian)
* Name: ____________________________________________
* Relationship: _______________________________________
* Phone Number(s): ___________________________________
________________


Reason for Counseling
* Please briefly describe the main concerns or reasons for seeking counseling for your child:

________________
________________
* Has your child received counseling or mental health services before? Yes / No
If yes, please provide details (when, where, reason):

________________
________________


Medical and Mental Health History
   * Does your child have any medical conditions or allergies? Yes / No
If yes, please describe:

________________
   * Is your child currently taking any medications? Yes / No
If yes, please list:

________________
   * Has your child been diagnosed with any mental health conditions? Yes / No
If yes, please specify:

________________
   * Are there any recent significant events or changes in your child’s life? (e.g., family changes, trauma, etc.)

________________
________________


Additional Information
      * What are your goals or hopes for your child’s counseling?

________________
________________
      * Is there anything else you would like the counselor to know?

________________
________________


Consent for Counseling
I, ____________________________________ (parent/guardian name), hereby give consent for my child, __________________________________ (child’s name), to receive counseling services.
Signature: ____________________________    Date: _______________
________________


Would you like me to create this as a fillable Google Form or a Google Doc template for you?

Yes


________________


Child Counseling Intake Form
Child's Information

Full Name: _______________________________________

Date of Birth: ____________________________________

Age: ___________________________________________

Gender: ________________________________________

School: _________________________________________

Grade: __________________________________________

Preferred Pronouns: _______________________________
________________


Parent/Guardian Information

Name(s): ________________________________________

Relationship to Child: _____________________________

Phone Number(s): __________________________________

Email Address: ___________________________________

Preferred Method of Contact: Phone / Email / Text
________________


Emergency Contact Information (other than parent/guardian)

Name: ____________________________________________

Relationship: _______________________________________

Phone Number(s): ___________________________________
________________


Reason for Counseling

Please briefly describe the main concerns or reasons for seeking counseling for your child:
________________
________________


Has your child received counseling or mental health services before? Yes / No

If yes, please provide details (when, where, reason):
________________
________________


Medical and Mental Health History

Does your child have any medical conditions or allergies? Yes / No

If yes, please describe:
________________


Is your child currently taking any medications? Yes / No

If yes, please list:
________________


Has your child been diagnosed with any mental health conditions? Yes / No

If yes, please specify:
________________


Are there any recent significant events or changes in your child’s life? (e.g., family changes, trauma, etc.)
________________
________________


Additional Information

What are your goals or hopes for your child’s counseling?
________________
________________


Is there anything else you would like the counselor to know?
________________
________________






Consent for Counseling
I, ____________________________________ (parent/guardian name), hereby give consent for my child, __________________________________ (child’s name), to receive counseling services.
Signature: ____________________________    Date: _______________