Child Intake Form - Acuity Counselling & Therapy

Home
Our practice
Veteran Support
Contact Us
Join Us

CHILD/ADOLESCENT INTAKE FORM
(please complete on behalf of your child)

* Indicates required field

Name of person completing this form *

First

Last

Your relation to the child *

Phone Number *

Email *

Name of other parent/legal guardian *

First

Last

Phone Number *

Email *

Child's Name *

First

Last

Age *

Date of birth *

DD/MM/YY

Gender at birth *

How does your child self identify? *

Home Address *

Name of child's school *

Grade/Year *

Families come in all configurations – please list the people who are in you child’s family. This can include all who live in the household/households as well as extended family (grandparents, etc) who are regularly in caregiving roles. Please include ages of siblings if there are any.

Who does the child live with? *

Current custody status: *

Any Pets? *

Please describe the reasons for your child's visit *

When did these problems start? What was going on in your child's life at that time? *

On a scale of 1 to 10 where 1 is Mild and 10 is Severe, how intense is your child's emotional distress? *

On a scale of 1 to 10 where 1 is Mildly Disruptive and 10 is Incapacitating, overall, how much do the problems affect your child's ability to perform at school, get along with others, and perform daily tasks such as chores? *

Please describle your child's temperament as an infant *

Please describe your child's temperament as a toddler *

Describe your child's functioning at school. Are there any problems? What are his/her school-related likes and dislikes? *

Describe how your child gets along with other children. Who are his/her best friends? *

Have you ever had concerns that your child was not meeting their developmental milestones or been told that they were not meeting milestones (examples – sitting up, crawling, walking, smiling, language, social skills, fine and gross motor skills, etc.) *

Has your child received mental health treatment or medication in the past? *

If yes, please indicate at what age, what was it for and if it helped *

Does your child currently have a mental health diagnosis? *

If yes, what is the current mental health diagnosis? *

Does your child have a developmental diagnosis (examples – ADHD, Autism Spectrum) *

If yes, what is the current developmental diagnosis? *

Please list any medical or physical problems that your child has been diagnosed with. *

Please list any medications that your child currently takes, and what they are taken for. *

Do you have a family doctor or pediatrician? *

If yes, please list name and phone number. *

Please tell us about any other professional supports your child receives or has received in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment). Examples include speech/language pathologist, occupational therapist, psychiatrist, etc. *

Is there any family history of mental health diagnosis? *

If yes, please describe. *

Please describe your child's current habits in each of the following areas. For example, how long and how often does your child engage in these activities. If your child does not engage in a listed activity please leave it blank.

Smoking *

Drinking *

Drug use *

TV use *

Internet use *

Video game use *

Exercise *

Chores & Responsibilities *

Fun & Relaxation *

Please describe your child’s current sleep habits (amount of sleep typically, bed and wake times, do they sleep through the night? Prefer their own bed or parent’s bed? Any sleep related fears? Bedwetting? Etc.) *

Please describe your child's eating habits or if you have any significant concerns about your child’s eating habits? For example, food preferences, quantities, etc. *

Some families are busy with many organised activities, others value more unstructured time – please briefly describe your child’s after-school and weekend activities. *

What is the approximate average screen time (all devices included) does your child spend on weekdays? *

What is the approximate average screen time (all devices included) does your child spend on weekends? *

Has your child experienced significant or stressful life events that are relevant to their therapy? Please select all that apply. *

A recent move or change in school Abuse or neglect Bullied or ignored by peers Academic difficulties Weight control issues Sexual orientation concerns Self-injury/Self-harm Death or Illness of a loved one or pet Family conflict Domestic violence Separation or Divorce Other

If you selected any of the above please describe the details below. *

What are your child’s positive qualities and skills? What do you like about your child? What qualities have helped your child to succeed at overcoming difficulties in the past? *

What are your child's interests? *

What are some goals for your child’s therapy? What would you like them to achieve by attending therapy? *

What concerns do you have about your child attending therapy or working on these problems? *

Is there anything else that you would like to mention or that you would like us to know about? *

Please make sure you have completed the form. Once you click SUBMIT you will not be able to review your answers.

SUBMIT

LOCATION
7071 Bayers Road, Suite 320
(in the Starlite Gallery)
Halifax, NS, B3L 2C2

CONTACT INFO
Phone: 902.406.3400
Fax: 902.406.4775
Email: [email protected]

BOOK AN APPOINTMENT today

HOURS OF OPERATION
Our therapists have varying schedules. We operate Monday to Friday from 9am to 7pm. We offer daytime and evening appointments.

LICENSING BODIES
The Nova Scotia Board of Examiners in Psychology
Nova Scotia College of Social Workers

©2025 Acuity Counselling and Therapy Services Inc. All rights reserved.
©2025 Website design by Noha Elkarmalawy.
FAQ | Privacy

Home
Our practice
Veteran Support
Contact Us
Join Us