Intake Child and Adolescent

.________________________________________ Child & Adolescent Intake Form Present During Session: Mother, Father, and Child (Sarah, age 10) Date of Appointment: 1 November 2024 ________________________________________ Child/Young Person’s MSE Mental Status Examination (MSE) MSE Section Assessment Appearance Well-groomed ☐ Dishevelled ☐ Malodorous ☐ Other: [describe other aspects of appearance] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Behaviour Calm ☐ Agitated ☐ Restless ☐ Cooperative ☑ Uncooperative ☐ Other: [describe other aspects of behaviour] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Speech Normal Rate ☑ Slow ☐ Rapid ☐ Pressured ☐ Monotone ☐ Other: [describe other aspects of speech] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mood ☐ Euthymic ☐ Depressed ☐ Anxious ☑ Irritable ☐ Elevated ☐ Other: [describe other aspects of mood] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Affect ☐ Full Range ☐ Restricted ☐ Flat ☐ Labile ☐ Congruent ☑ Incongruent ☐ Other: [describe other aspects of affect] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Thought Process Logical ☑ Disorganised ☐ Flight of Ideas ☐ Tangential ☐ Circumstantial ☐ Unable to assess ☐ Other: [describe other aspects of thought process] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Thought Content No delusions ☑ Paranoid ☐ Suicidal ☐ Homicidal ☐ Obsessions ☐ Other: [describe other aspects of thought content] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Perception No hallucinations ☑ Auditory ☐ Visual ☐ Tactile ☐ Other: [describe other aspects of perception] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Cognition Alert ☑ Disoriented ☐ Memory Impairment ☐ Inattention ☐ Confused ☐ Other: [describe other aspects of cognition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Insight Good ☐ Limited ☐ Poor ☐ Other: [describe other aspects of insight] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Judgment Intact ☑ Impaired ☐ Poor ☐ Other: [describe other aspects of judgment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Family Tree & Dynamics Please list immediate and extended family members who play a significant role in the child’s life. Name Relationship Age Lives with Child? (Yes/No) Mental Health Concerns? (Yes/No) Sarah Smith Child 10 ☑ Yes ☐ No ☐ Yes ☐ No John Smith Father 40 ☑ Yes ☐ No ☐ Yes ☐ No Mary Smith Mother 38 ☑ Yes ☐ No ☐ Yes ☐ No Grandma Grandmother 65 ☐ Yes ☑ No ☐ Yes ☐ No • Additional family background notes: Grandmother lives nearby and provides childcare support. ________________________________________ Are there any family stressors impacting the child? ☐ Divorce/Separation ☐ Loss of a family member ☐ Illness ☑ Financial stress ☐ Other: [describe other family stressors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Presenting Concerns • What concerns have led you to seek therapy for your child? Sarah is exhibiting increased irritability, difficulty sleeping, and withdrawal from social activities. She is also struggling with school performance. • How long have these concerns been present? These concerns have been present for approximately three months. • What goals do you hope to achieve through therapy? Parents hope Sarah will improve her mood, sleep better, re-engage in social activities, and improve her school performance. • Current stressors affecting the child (check all that apply): ☑ School ☐ Family ☑ Friendships ☑ Anxiety ☑ Depression ☑ Behaviour ☐ Self-Esteem ☐ Bullying ☐ Sleep ☐ Other: [describe other current stressors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Developmental & Medical History • Were there any complications during pregnancy, birth, or early development? ☐ No ☐ Yes (Please describe): [describe complications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Any significant developmental delays (e.g., speech, walking, motor skills)? ☐ No ☐ Yes (Please describe): [describe developmental delays] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child have any diagnosed medical conditions? ☐ No ☐ Yes (Please list): [list diagnosed medical conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child take any medications? ☐ No ☐ Yes (List name & dosage): [list medications and dosages] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child have any allergies? ☐ No ☐ Yes (List allergens): [list allergens] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Has your child had any major illnesses, hospitalizations, or surgeries? ☐ No ☐ Yes (Details): [describe major illnesses, hospitalizations, or surgeries] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Mental Health & Behavioural History • Has your child previously seen a psychologist, psychiatrist, or counsellor? ☐ No ☐ Yes (When & for what reason?): [describe previous mental health consultations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Has your child been diagnosed with a mental health condition? ☐ No ☐ Yes (Please specify): [specify mental health condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child have a history of self-harm or suicidal thoughts? ☐ No ☐ Yes (Details): [describe history of self-harm or suicidal thoughts] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Has your child displayed aggressive or harmful behaviors toward others? ☐ No ☐ Yes (Details): [describe aggressive or harmful behaviors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Education & Learning • How does your child perform in school academically? ☐ Above Average ☐ Average ☑ Below Average • Has your child had any learning difficulties or diagnoses (e.g., ADHD, Dyslexia, Autism)? ☐ No ☐ Yes (Please specify): [specify learning difficulties or diagnoses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child receive any additional support at school (e.g., IEP, therapy, tutoring)? ☐ No ☐ Yes (Please describe): [describe additional support at school] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Has your child ever been suspended or expelled? ☐ No ☐ Yes (Details): [describe suspensions or expulsions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Social & Emotional Well-Being • How would you describe your child’s personality? ☐ Outgoing ☐ Shy ☑ Anxious ☐ Confident ☐ Sensitive ☐ Other: [describe other aspects of personality] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child have close friendships? ☐ Yes ☑ No • Have there been any recent major changes in your child’s life (e.g., divorce, move, loss of a loved one)? ☐ No ☐ Yes (Details): [describe recent major changes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Does your child have difficulty managing emotions (e.g., anger, frustration, sadness)? ☐ No ☑ Yes (Details): [describe difficulties in managing emotions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) ________________________________________ Additional Information • Are there any cultural or religious factors that should be considered in therapy? ☐ No ☐ Yes (Please describe): [describe cultural or religious factors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) • Anything else you’d like the psychologist to know about your child? Sarah enjoys playing video games and has expressed feeling overwhelmed by schoolwork. 10. Confidentiality & Consent Explained and understood: o YES o NO “I understand that the information provided is confidential and will not be shared without my consent, except in cases where disclosure is required by law (e.g., risk of harm to self/others, child abuse). ________________________________________ (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)