Adolescent Telehealth Psychotherapy Intake Form Home » Adolescent Telehealth Intake Form (Confidential – For Clinical Use Only) Adolescent Telehealth Intake Form "*" indicates required fields X/TwitterThis field is for validation purposes and should be left unchanged.Adolescent InformationFull Name*Preferred NameDate Of Birth MM slash DD slash YYYY AgeGender IdentityPronounsAddress Street Address City State ZIP Code Phone*Email (if applicable) SchoolGradeParent/Guardian Information Parent/Guardian 1Name*Relationship to ChildPhone*Email* Parent/Guardian 2NameRelationship to ChildPhoneEmail Legal Custody Arrangement Joint Sole (by Parent 1) Sole (by Parent 2) Other Other*Emergency Contact (name/phone)Referral & Reason for TherapyHow Did You Hear About This Practice?What Concerns Led You to Seek Therapy for Your Child?Has Your Child Received Counseling or Psychiatric Treatment Before? Yes No If Yes, Please DescribePresenting Concerns (check all that apply) Anxiety / excessive worry Sadness / depression Anger / irritability Peer or friendship difficulties Bullying (victim or perpetrator) Family conflict School / academic problems Attention / concentration issues Behavioral concerns (e.g., defiance, aggression) Trauma history Self-Esteem Concerns Sleep problems Risk of self-harm or suicidal thoughts Other Other*Medical & Mental Health HistoryPrimary Care PhysicianCurrent MedicationsPast or Current DiagnosesPrevious Hospitalizations (medical or psychiatric)Relevant Medical Conditions:Developmental & Social BackgroundPregnancy/birth History (if significant)Developmental Milestones (speech, motor, etc.) On time Delayed (please explain): Delayed (Please Explain):*Discipline Style at HomeStrengths and Interests (Sports, Hobbies, Talents)Social Supports (friends, relatives, activities)Telehealth Consent & ConsiderationsDo You and Your Child Have Access to a Private Space for Sessions? Yes No Preferred Device for Sessions Computer Tablet Phone Internet Access Reliability Good Fair Poor Parent/Guardian Consent* Parent/Guardian Consent:*I understand that telehealth involves using secure video technology to provide psychotherapy. I acknowledge that: - Confidentiality will be maintained, except in cases of suspected abuse, risk of harm, or as otherwise required by law. - Telehealth has potential risks (e.g., technical issues, interruptions). - I must ensure my child’s privacy and appropriate environment during sessions.I consent for my child, Name*to participate in telehealth psychotherapy with Dr.Name*Parent/Guardian 1 SignatureDate MM slash DD slash YYYY Parent/Guardian 2 SignatureDate MM slash DD slash YYYY Adolescent Assent (if age-appropriate):* Adolescent Assent (if age-appropriate):*I understand that therapy is a safe space to talk, and I agree to participate.Signature*Date* MM slash DD slash YYYY
