Intake Form- Children | Psychological Assess

VCAT Psychological Assessment Center at VCAT Treatment Center

Children/Adolescents Intake Form

Date:

Client Information

Child’s Full Name:

Date of Birth / Age

Gender:

Male

Female

School Name & Grade:

Home Address:

Parent/Guardian Name(s):

Relationship to Child:

Phone

Email

🏥 Referral Information a heading

Reason for Referral: (e.g., behavioral concerns, academic difficulties, emotional distress, developmental delays). Describe in details.

Who referred the child for assessment?

Has the child received previous psychological or psychiatric services? If yes, please describe include all dates of provided services.

🧠 Presenting Concerns

Please check all that apply:

🏡 Family & Developmental History

Any significant medical or developmental concerns?

Pregnancy and birth complications (if any):

Milestones (e.g., walking, talking):

Current family structure (e.g., parents, siblings, guardians):

Any history of mental health issues in the family? If yes, please specify:

🏫 School Functioning

Current academic performance: -IEP or 504 Plan in place?

Yes

No

Behavioral concerns at school? If yes, please describe!

💊 Medical & Psychiatric History

Current medications:

Allergies:

Past hospitalizations or major illnesses:

Previous psychological evaluations or diagnoses:

Parental Consent for Psychological Evaluation

As the parent or legal guardian of the child named above, I authorize VCAT Treatment Center and its licensed psychologists to conduct a psychological assessment.

Yes

No

Signature

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Psychological Assessment and Evaluations

At VCAT Treatment Center Costa Mesa Orange County