Have you ever been involved in criminal or civil proceedings? (circle Yes one) No If yes, please explain. (check all that apply): Suspended/Revoked driver’s license Shoplifting Conviction for misdemeanor Assault/Battery Conviction for felony Property Damage DUI/DWI Other Please explain. Have you ever been charged or arrested for any offense involving drugs or alcohol? (circle Yes No one) If yes, please explain. Are you currently on probation? (circle Yes No one) If yes, please explain the reason and terms of probation. Is there a family history of legal problems? (circle Yes No one) If yes, please explain. Notes: Medical History Please describe the client’s current physical health. Is the client currently taking medication? (circle Yes No one) Please describe. Has the client have allergies? (circle Yes one) No If yes, please explain. Has the client ever had a serious accident or injury? (circle Yes one) No If yes, please explain. Has the client ever been medically hospitalized? (circle Yes No one) If yes, please explain.
Have you ever been involved in criminal or civil proceedings? (circle one) Yes No If yes, please explain. (check all that apply): Suspended/Revoked driver’s license Conviction for misdemeanor Conviction for felony DUI/DWI Shoplifting Assault/Battery Property Damage Other Please explain. Have you ever been charged or arrested for any offense involving drugs or alcohol? (circle one) Yes No If yes, please explain. Are you currently on probation? (circle one) Yes No If yes, please explain the reason and terms of probation. Is there a family history of legal problems? (circle one) Yes No If yes, please explain. Notes: Medical History Please describe the client’s current physical health. Is the client currently taking medication? (circle one) Yes No Please describe. Has the client have allergies? (circle one) Yes No If yes, please explain. Has the client ever had a serious accident or injury? (circle one) Yes No If yes, please explain. Has the client ever been medically hospitalized? (circle one) Yes No If yes, please explain.
Child-Intake-Form-for-web.docx