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Broward Center for Counseling
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Release of Information Form
Common Questions
Contact
Minor Intake Form
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Minor Intake Form
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Minor Intake Form
The information requested in this questionnaire is necessary for the planning of the services to be rendered to your child. Please fill it out as completely as possible. If you do not understand a question or do not know the answer, please leave that question blank. However, please try and answer fully as many questions as you possibly can. It is understandable that you might be concerned about what happens to the information about you because much or all of this information is highly personal. Case records are strictly confidential. NO OUTSIDER IS PERMITTED TO SEE YOUR CASE RECORD WITHOUT YOUR PERMISSION. If you do not desire to answer any questions, merely write “Do not care to answer”.
PATIENT INFORMATION
Today's Date
MM slash DD slash YYYY
Referred By:
Minor's Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Age
(Required)
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Sex
(Required)
Male
Female
Your Address
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
GUARDIAN INFO
Mother's Name
(Required)
First
Last
Mother's Phone
Mother's Email
Father's Name
(Required)
First
Last
Father's Phone
Father's Email
Child resides with:
Mother
Father
Both Natural Parent(s)
Foster Parent(s)
Other
INSURANCE INFORMATION (PRIMARY)
Name of Insured
Insured's Date of Birth
MM slash DD slash YYYY
Relationship
Father
Mother
Legal Guardian
Sibling
Grandparent
Name of Carrier
Member ID
Group #
Employer Name/Company
Occupation
Work Phone
Do you have Secondary Insurance?
(Required)
Yes
No
INSURANCE INFORMATION (SECONDARY)
Name of Insured
Insured's Date of Birth
MM slash DD slash YYYY
Name of Carrier
Member ID
Group Member
Yes
No
Family History
Other people living in the home?
How many other people live in your home?
(Required)
0
1
2
3
4
5
6
Household Member #1
First
Last
Household Member #1 Age
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Household Member Relationship #1
Father
Mother
Legal Guardian
Sibling
Step-Sibling
Grandparent
Household Member Highest Grade Completed #1
No formal education
Primary education
Secondary education or high school
GED
Vocational qualification
Bachelor's degree
Master's degree
Doctorate or higher
Household Member #2
First
Last
Household Member #2 Age
1
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125
Household Member Relationship #2
Father
Mother
Legal Guardian
Sibling
Step-Sibling
Grandparent
Household Member Highest Grade Completed #2
No formal education
Primary education
Secondary education or high school
GED
Vocational qualification
Bachelor's degree
Master's degree
Doctorate or higher
Household Member #3
First
Last
Household Member #3 Age
1
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125
Household Member Relationship #3
Father
Mother
Legal Guardian
Sibling
Step-Sibling
Grandparent
Household Member Highest Grade Completed #3
No formal education
Primary education
Secondary education or high school
GED
Vocational qualification
Bachelor's degree
Master's degree
Doctorate or higher
Household Member #4
First
Last
Household Member #4 Age
1
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120
121
122
123
124
125
Household Member Relationship #4
Father
Mother
Legal Guardian
Sibling
Step-Sibling
Grandparent
Household Member Highest Grade Completed #4
No formal education
Primary education
Secondary education or high school
GED
Vocational qualification
Bachelor's degree
Master's degree
Doctorate or higher
Household Member #5
First
Last
Household Member #5 Age
1
2
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5
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121
122
123
124
125
Household Member Relationship #5
Father
Mother
Legal Guardian
Sibling
Step-Sibling
Grandparent
Household Member Highest Grade Completed #5
No formal education
Primary education
Secondary education or high school
GED
Vocational qualification
Bachelor's degree
Master's degree
Doctorate or higher
Education
Schools Attended
Academic Grades
Grade Levels
Preschool
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
College
Grades
Academic Concerns
Current / Previous Concerns
Current Concerns
Speech Problems
Behavior Problems
Hyperactivity
Aggression
Sexual Activity
Poor School Behavior
Problems w/teacher
Problems w/authority
Problems w/peers
Difficulty sleeping
Difficult to discipline
Gets upset easily
Temper tantrums
Nail Biting
Thumb sucking
Legal problems
Problems w/alcohol
Nightmares
Bedwetting
Masturbating excessively
Problems w/drugs
Depression
Anxiety
Suicidal thoughts or Attempts
Problems w/eating
Death in family
Parents separated / Divorced
Parents remarried
Recent move or plans to move
What are you most concerned about with child?
What is your child most concerned about?
What does the school believe to be the problem?
In what situations is the problem most apparent?
Least apparent?
Who generally disciplines the child?
What methods are used?
Do parents agree on methods of discipline?
Yes
No
Elaborate if “no”
Medical Information
Minor's Primary Physician Name
Primary Physician Phone
Physician's Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Is your child currently on any medications?
(Required)
Yes
No
If yes, what medications and dosages are they on?
List below any disease, conditions or other medical problems including vision or hearing your child/adolescent has experienced and his/her age at that time:
Have you consulted other therapists or psychiatrist regarding your child/adolescent?
Yes
No
Physician Name
First
Last
Physician Phone
Type of Doctor
Therapist
Psychiatrist
Medical Communication Consent
Contacting Doctors: We believe we can offer the utmost quality of care by working as a team with your other healthcare providers. I am willing to allow “Broward Center for Counseling” to discuss information regarding services provided at this office:
Can we communicate with your Physicians?
Primary Care
Psychiatrist
Choose all we have permission to contact
Primary Care Physician
Primary Care Physician Name:
First
Last
Primary Care Phone
Primary Physician Fax
Psychiatrist
Psychiatrist Name:
First
Last
Psychiatrist Phone:
Psychiatrist Fax:
Acknowledgement
Preferred phone number to reach you:
May we leave a message for you on your voicemail?
Yes
No
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