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Intake assessment example

Intake assessment example 2026

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The document is a Child Intake Assessment Form created by Dr. Jason G. Stentoumis, a licensed psychologist. It is designed to collect comprehensive information about a child seeking psychological treatment, including identifying details, family background, reasons for seeking help, history of the problem, family health issues, educational challenges, developmental milestones, medical care history, and the child's interests and activities. The form aims to gather relevant data to assist in understanding the child's needs and providing appropriate therapeutic support.

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Click ‘Get Form’ to open the intake assessment example in the editor.
Begin by filling out the 'Identifying Information' section. Enter the child's name, today's date, date of birth, age, grade, sex, race/ethnicity, and social security number. Ensure all fields are completed accurately.
Proceed to the 'Mother’s Information' section. Fill in details such as name, date of birth, home phone number, address, race/ethnicity, and employment status. Check the appropriate boxes for marital status and provide any special calling instructions.
Continue with the 'Father’s Information' and 'Step-parent’s Information' sections using similar guidelines as above. Make sure to include all relevant details.
In the 'Reason for Seeking Treatment' section, describe your child's issues and what you hope to achieve through treatment. Be thorough yet concise.
Complete the remaining sections regarding family history, education, development, medical care, and interests. Each section is designed to gather comprehensive information about your child.

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Versions	Form popularity	Fillable & printable
2016	4.2 Satisfied (44 Votes)

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What happens during an intake interview?

Intake interviews include an intake assessment which is a comprehensive evaluation of personal history, family background, medical history, symptoms, and any previous treatment experiences. Questions asked during an intake assessment are often dependent on the type of services being provided by the professional.

What is an intake assignment?

The Brief Intake/Assessment is the initial meeting with the client during which the case manager gathers information to address the clients immediate needs to encourage his/her engagement and retention in services.

What is another name for the intake assessment?

Many providers call the intake assessment the bio-psycho-social assessment, which functions like a shorthand for the key points you need to address with your client: their biological history, their psychological history, and their social history.

What is a brief intake assessment?

Inquiries like Tell me about your family and your relationships with them, Can you tell me about your childhood and any docHub experiences that shaped who you are today? and Are there any cultural, religious, or personal values that are particularly important to you? can provide valuable insights into their

What is an intake assessment?

Examples from Collins dictionaries Your intake of alcohol should not exceed two units per day. Reduce your salt intake. The airline is to double the intake of its female pilots. It is important to ensure that solid objects do not enter the air intake of the jet engine.

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