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Includes sections for child identity, custody/visitation comments, primary concerns, and a symptom or problem checklist covering emotional, behavioral, attention, social, and safety-related issues. Captures school history, pregnancy and birth details, developmental milestones, health history in early years, current medications and allergies, domestic violence exposure, discipline methods, life stressors/trauma history, strengths, and signature with date for completion.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/child-intake-form-please-complete-in-ink/307630/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/child-intake-form-please-complete-in-ink/307630.png","ImageObject",442,249,{"name":88,"@type":89},"4398046744996","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is requested about the child in the form?","Question",{"text":109,"@type":110},"The form requests the child’s name, sex, age, and date of birth, plus whether the child is natural, adopted (including age and foster timeframe), or fostered.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form assess a child’s concerns?",{"text":114,"@type":110},"It includes a symptom/problem checklist where caregivers check symptoms of concern and indicate how long the issues have been present.",{"name":116,"@type":107,"acceptedAnswer":117},"What medical and developmental history fields are included?",{"text":118,"@type":110},"The form asks about pregnancy and delivery details, developmental milestones, early health experiences, the child’s doctor and last physical exam date, vision/hearing/dental issues, head injuries, serious illnesses or hospitalizations, medications, and allergies.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},307630,1790298519,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":60,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":73},4398046744996,"CHILD INTAKE FORM  \n(Please complete in Ink)  \nCHILD  \n1. Child’s Name  Sex Age  DOB   \n2. Natural Child Yes / No If adopted, at what age  Foster since    \n3. Parent’s Names (include step-parents, foster parents, inc. )  \n________________________________________________________________________  \n4. Comments about custody and visitation (if applicable):  \n5. Primary reason you are concerned about your child?  \n________________________________________________________________________  \n__________________________________________________________ ______________  \nSYMPTOM/PROBLEM CHECKLIST  \nCheck any symptom that is a concern. How long has it been a problem?  \na.   Sleep problems   Morbid thoughts   Lack of interest in activities   Suicidal thoughts or threats   Unassertive   Suicidal plans / attempts   Fatigue/low energy   Mood swings   Concentration problems   Depression   Appetite/weight changes   Changed level of activity   Withdrawal   Cries easily  \nb.   Forgetful/memory problems   Talks excessively / interrupts   Short attention span   Easily distracted   Aggressive behavior   Irritable  \n  Can’t sit still   Impulsive  \n  Not interested in peers   Difficulty following rules  \n  Picked on / bullied by peers   Problem completing schoolwork  \nc.   Excessive worry / fearfulness   Nightmares  \n  Anxiety or panic attacks   Frequent tantrums  \n  Social fears, shyness   Resistive to change  \n  Separation problems   School refusal  \n  Bedwetting / soiling   Perfectionism  \n  Headaches, stomachaches   Odd hand / motor movements  \n  Odd beliefs / fantasizing   Hallucinations  \nd.   Lying   Stealing  \n  Trouble with the law   Being destructive  \n  Running away   Fire setting  \n  Truancy, skipping school   Hurting others / fighting  \n  Hurting others sexually   Acts as if has no fear  \n  Alcohol / drug use   Short tempered  \n  Argumentative / defiant   Easily annoyed / annoys others  \n  Swears   Discipline problem  \n  Blames others for mistakes   Angry and resentful  \n\n| First Name – Last Name | Sex | Age | Relationship to child (full, step, half, foster) |\n| --- | --- | --- | --- |\n| 1. |  |  |  |\n| 2. |  |  |  |\n| 3. |  |  |  |\n| 4. |  |  |  |\n| 5. |  |  |  |\n| 6. |  |  |  |\n\nBrothers and Sisters  \nSCHOOL HISTORY  \n1. Present School:   Grade:   Teacher:   \n2. Has child ever repeated any grade?    \n3. Is child in special education services? No   Yes, what kind?    \n4. Please describe academic or other problems your child has had in school  \nCHILD’S DEVELOPMENTAL AND MEDICAL HISTORY  \n1. Pregnancy  \nMother used during pregnancy: alcohol   drugs   cigarettes    \nDelivery: Normal   Breech   Cesarean   Transectional   Full-term   Premature   if premature, number of weeks    \nBirth Weight:    \nProblems at birth: (for example: infant given oxygen, blood transfusion, placed in an Incubator, etc)  \n2. Developmental History  \n􀁸 State approximate age when child did the following:  \nWalked alone   Said first word   Used 2-word phrases    \n􀁸 Understood and followed simple directions    \n􀁸 Reasonably well toilet trained    \n􀁸 Did child cry excessively?   Rarely cried    \n3. Health History of Child  \nIn the first two years, did your child experience:   Separation from mother,   Out of home care,   Disruption in bonding,   Depression of mother,  Abuse,   Neglect,   Chronic pain,   Chronic Illness,   Parental Stress  \n􀁸 Child’s Doctor:    \n􀁸 Date of last physical exam:    \n􀁸 Vision problems? Yes   No  Hearing problems? Yes   No    \n􀁸 Dental problems? Yes   No    \n􀁸 Any head injuries or loss of consciousness? Yes   No    \n􀁸 Child’s history of serious illness, injury, handicaps, or hospitalization?  \nNo   Yes – describe and give dates    \n􀁸 Is your child currently taking any medications? No   Yes   name medications  \n􀁸 List any medicines previously used for emotional problems: were they helpful?    \n􀁸 Allergies to drugs or medicines? No   Yes   (list)    \n􀁸 Allergies to any foods? No   Yes   (list)    \n􀁸 Are there any foods that you limit or do not give t","cbCaighj4kgWcpsO","https://ap.wps.com/l/cbCaighj4kgWcpsO","pdf",181130,6,"English","# CHILD\n## Child’s Name, Sex, Age, DOB\n## Natural Child / Adopted / Foster Details\n## Parent’s Names and Custody/Visitation Comments\n# SYMPTOM/PROBLEM CHECKLIST\n## Sleep, Mood, Concentration, Depression\n## Memory, Attention, Behavior, Aggression\n## Anxiety, Worry, Tantrums, Nightmares\n## Lying, Stealing, Legal Trouble, Self-Control","[{\"question\":\"What information is requested about the child in the form?\",\"answer\":\"The form requests the child’s name, sex, age, and date of birth, plus whether the child is natural, adopted (including age and foster timeframe), or fostered.\"},{\"question\":\"How does the form assess a child’s concerns?\",\"answer\":\"It includes a symptom/problem checklist where caregivers check symptoms of concern and indicate how long the issues have been present.\"},{\"question\":\"What medical and developmental history fields are included?\",\"answer\":\"The form asks about pregnancy and delivery details, developmental milestones, early health experiences, the child’s doctor and last physical exam date, vision/hearing/dental issues, head injuries, serious illnesses or hospitalizations, medications, and allergies.\"}]","CHILD INTAKE FORM - Please complete in Ink | PDF",1789852213]