Child Intake

____ presented for this intake session seeing support for _____. Parent/caregiver described the following presenting problem: 
[textarea name="PresentingProblem" cols="50" rows="10"]
Therapist reviewed confidentiality, limits of confidentiality and duty to protect. Caregivers provided verbal consent for treatment in addition to signatures on intake/consent forms. 
[checkbox name="Teleheatlh" value="______ presented via Telehealth. Therapist confirmed location and commented on secure space to ensure confidentiality."]
Therapist conducted clinical interview. Caregivers shared the following:
[checkbox name="Family" value="Family "]
[textarea name="Family1" cols="50" rows="10"]
[checkbox name="FamilyHistory" value="Family history | No signifiant family history revealed at intake"]
[textarea name="FamilyHistory1" cols="50" rows="10"]
[checkbox name="MedicalHistory" value="Medical History|No significant medical history revealed at intake"]
[textarea name="MedicalHistory1" cols="50" rows="10"]
[checkbox name="SocialEmotional" value="Social-Emotional"]
[textarea name="SocialEmotional1" cols="50" rows="10"]
[checkbox name="School" value="School"]
[textarea name="School1" cols="50" rows="10"]
[checkbox name="SleepDiet" value="Sleep Related Factors| Diet Related Factors| No significant sleep or diet information provided at intake"]
[textarea name="SleepDiet1" cols="50" rows="10"]
[checkbox name="AccommodationsStrategies" value="Current Strategies and Acccommodations"]
[textarea name="AccommoationsStrategies1" cols="50" rows="10"]
[checkbox name="TreatmentGoals" value="Therapist suppored caregivers to idetnify the following treatment goals"]
[textarea name="TreatmentGoals1" cols="50" rows="10"]
[checkbox name="Assessment" value="Thearpist provided the following rating scale/assessment to gather baseline data related to the presenting problem."]
[textarea name="Assessment" cols="50" rows="10"]
[checkbox name="Modalities" value="Therapist discussed evidenced-based modalities to target treatment goals"]
[textarea name="Modalities1" cols="50" rows="10"]