Intake Form | Adam's House

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Adam's House Intake Questionnaire

Please complete this questionnaire. This is for in-house use only will not be shared with a 3rd party.

Parent Name or Adult Participant

First Name

Last Name

Your relationship to child/children:

Street Address

City

Region/State/Province

Postal / Zip code

Daytime Phone

Cell Phone

Email

Employment Status

Employer

Can you be contacted at work?

Yes

No

Emergency Contact:

Emergency Contact Relationship to the child?

Emergency Contact Phone:

Please list everyone who will be attending Adam's House including yourself:

Adam's House Children Name(s):

Child 1, Current Age

Child 2

Child 3

Date of Birth

Gender

Name of the Loved One who passed away?

Primary Cause of Death:

Additional Info Regarding the Loved One who passed away?

Your Relationship to the deceased?

Date of Birth

Date of Death

Have the children been told everything about how the loved one passed?

Yes

No

If No, what have they not been told?

What other changes has your family experienced in the last 12 months? (moves, school changes, other losses, etc.)

Is anyone in the family experiencing any of the following since the passing?

Loss of Appetite

Increased Irritability

Sleeplessness

Violent Behavior

Attempted Run Away

Other (please explain)

Other, additional Info:

Any family members currently receiving counseling or therapy?

Yes

No

If yes, what is the name of counselor?

Please list any medication(s) your child(ren) is taking and/or allergies:

Child's Name

Medication

Allergies

Child's Name

Medication

Child's Name

Medication

Allergies

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