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Adolescent & Child Intake Information

Adolescent & Child Intake Information

Please provide the following information and answer the questions below. Please note: Information you provide is protected as confidential
information.


SCHOOL HISTORY


DEVELOPMENTAL HISTORY


State approximate age when child did the following:


In the first two years, did your child experience:


FAMILY MENTAL HEALTH HISTORY

In this section, identify if there is a family history of any of the following. If yes, please indicate the family member’s relationship to you in
the space provided (ex. Father, grandmother, uncle, etc.)


LIFE STRESSORS/TRAUMA HISTORY


ADDITIONAL INFORMATION


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