Outcomes, Assessment Services, & Intervention Supports (OASIS) - Youth Client Intake - Part 2

Please provide the following information for our records. Leave any questions you prefer not to answer blank.

This website uses cookies and other technologies to improve the functionality and performance of this site and your experience. Learn more by reviewing our Privacy Policy.

Person completing this form:

First Name

Last Name

Is the person completing this form a guardian?

Relationship to child

Relationship to child (other)

Phone

- -

Please enter the first guardian's email address

Address

Street Address

City

State

Zip

Child

First Name

Last Name

Birthdate

format: MM-DD-YYYY

Age

Gender

Preferred Pronouns

Family History

Please check all items which apply.

Previous counseling

Current counseling

Inpatient mental health treatment

Suicide history and attempts

Depression and anxiety

Learning disabilities

Physical or sexual abuse

If applicable please list who (mother, father, extended family, when, circumstances, etc.)

Family history notes

If applicable please list who (mother, father, extended family, when, circumstances, etc.)

Developmental History

Pregnancy and delivery

Mother’s age during pregnancy?

(enter as numeral i.e. 21)

Father’s age during pregnancy?

(enter as numeral i.e. 21)

Bleeding

Excessive weight gain (more than 30 lbs.)

Toxemia/preeclampsia

Rh factor incompatibility

Frequent nausea or vomiting

Serious illness or injury

Took prescription medications

Took medications or recreational drugs on your own

Used alcoholic beverage

Smoked cigarettes

Was given medication to ease labor pains

Delivery was induced

Forceps were used during delivery

Had a breech delivery

Had a cesarean section delivery

Other birth complications or problems

Siblings

Sibling 1

Child’s name 1

Date of birth 1

Description of relationship-how do they get along? 1

Sibling 2

Child’s name 2

Date of birth 2

Description of relationship-how do they get along? 2

Sibling 3

Child’s name 3

Date of birth 3

Description of relationship-how do they get along? 3

Sibling 4

Child’s name 4

Date of birth 4

Description of relationship-how do they get along? 4

Sibling 5

Child’s name 5

Date of birth 5

Description of relationship-how do they get along? 5

Sibling 6

Child’s name 6

Date of birth 6

Description of relationship-how do they get along? 6

During the first 12 months, was your child:

Difficult to feed

Difficult to get to sleep

Colicky

Difficult to put on a schedule

Difficult to keep busy

Overactive, in constant motion

Very stubborn, challenging

Alert

Cheerful

Affectionate

Sociable

Easy to comfort

Health

At any time, has your child had a history of…

Asthma

Allergies

Diabetes, arthritis, or other chronic illnesses

Epilepsy or seizure disorder

Seizures with a fever

Chicken pox or other common childhood illnesses

Heart or blood pressure problems

High fevers (over 103°)

Broken bones

Severe cuts requiring stitches

Head injury with loss of consciousness

Lead poisoning

Surgery

Hospitalization for more than one night

Speech or language problems

Chronic ear infections

Hearing difficulties

Eye or vision problems

Fine motor/handwriting problems

Gross motor difficulties, clumsiness

Appetite problems (overeating or undereating)

Sleep problems (falling asleep, staying asleep)

Soiling problems

Wetting problems

Is your child left or right-handed?

Please list you child’s early developmental milestones

Sitting without help

Crawling

Walking alone, without assistance

Using single words (mama, dada, ball, more)

Using two or more words together (mama up)

Bowel training, day and night

Mental Health History

Has your child been evaluated by a psychologist or neuropsychologist in the past?

If yes, when?

Who completed the evaluation?

Has your child been in counseling or therapy in the past?

If yes, when?

Who provided the counseling/therapy

Is your child currently taking any prescribed psychiatric medication (antidepressants or others)?

If yes, please list

History of Abuse

Describe any history of neglect, verbal, emotional, physical, or sexual abuse

What actions were taken?

Master’s and doctoral students in our graduate programs staff the Outcomes, Assessment Services, & Intervention Supports (OASIS). To ensure quality of services you receive, all counselors in training are assigned faculty supervisors with whom to consult concerning the process of counseling. Your session may be both audio and video recorded. The purpose of recording is to provide instruction and feedback to students. All recorded materials and written records are restricted to the internal use of the OASIS and their confidentiality will be strictly safeguarded, with expectations discussed with your counselor in the first session. Recordings are delated after each semester.