Please describe cultural/ethnic identification and/or religious/spiritual affiliation and their role in family life. For what Problem(s) are you seeking help? General Behavior of Client/Child Patient(check all that apply): Friendly, Outgoing Optimistic Sharing Shy Pessimistic Selfish Easygoing, Calm Caring Respectful Irritable Uncaring Defiant Hardworking Cooperative Takes Risks Lazy Stubborn Cautious Prefers Company Confident Generally Happy Prefers to be Alone Expects Failure Generally Unhappy Notes: Problem Areas (check all that apply): Thoughts Worries Obsessive Odd Fears Compulsive Disturbing Behavior Compulsive Messy Short Attention Span Repetitive Inattentive Distractible Odd
Please describe cultural/ethnic identification and/or religious/spiritual affiliation and their role in family life. For what Problem(s) are you seeking help? General Behavior of Client/Child Patient(check all that apply): Friendly, Outgoing Shy Easygoing, Calm Irritable Hardworking Lazy Prefers Company Prefers to be Alone Optimistic Pessimistic Caring Uncaring Cooperative Stubborn Confident Expects Failure Sharing Selfish Respectful Defiant Takes Risks Cautious Generally Happy Generally Unhappy Notes: Problem Areas (check all that apply): Thoughts Worries Fears Obsessive Compulsive Odd Disturbing Behavior Compulsive Repetitive Odd Messy Inattentive Short Attention Span Distractible
Child-Intake-Form-for-web.docx