Parents divorced Step-sibling Suffered/Witnessed problems significant Parental visitation accident/injury Family economic problems Other severe fright problems Post-divorce or trauma Family job parental problems Death of family problems Parent(s) remarried member Other family Step-parent Death of friend problems problems Rejection by family Death of pet Sibling birth members Please describe. School History Current School: Street Address: City: State: Zip Code: Phone: ( ) Current Grade Level: Has the client repeated a grade? Please explain. Has the client skipped a grade? Please explain. Please describe the client’s academic grades. Is or has the client even been involved in special education? Please explain. Does the student have an IEP? yes no Is the student on a 504 plan? yes no Has there ever been any indication of a learning problem? Please describe. Please describe the client’s study habits. Please describe the client’s behavior in school. Has the client ever been suspended or expelled from school? Please explain.
Parents divorced Parental visitation problems Post-divorce parental problems Parent(s) remarried Step-parent problems Sibling birth Step-sibling problems Family economic problems Family job problems Other family problems Rejection by family members Suffered/Witnessed significant accident/injury Other severe fright or trauma Death of family member Death of friend Death of pet Please describe. School History Current School: Street Address: City: State: Zip Code: Phone: ( ) Current Grade Level: Has the client repeated a grade? Please explain. Has the client skipped a grade? Please explain. Please describe the client’s academic grades. Is or has the client even been involved in special education? Please explain. Does the student have an IEP? yes no Is the student on a 504 plan? yes no Has there ever been any indication of a learning problem? Please describe. Please describe the client’s study habits. Please describe the client’s behavior in school. Has the client ever been suspended or expelled from school? Please explain.
Child-Intake-Form-for-web.docx