Empower Purpose

Client Intake & Referral Assessment Form for Parents/Guardians

Date

Month

Day

Year

I. Parent/Guardian Information

Full Name

Relationship to Child:

Phone Number:

Email Address:

Address:

II. Child Information

Child’s Full Name:

Date of Birth:

Age:

Gender:

Male

Female

Other

School / Grade:

Languages Spoken:

III. Reason for Evaluation

If other, please describe the main concern or situation:

IV. Child’s Background

Has your child received counseling or therapy before?

Yes

No

If yes, where and when?

Is your child currently receiving mental health services or treatment?

Yes

No

Is your child taking any medication?

Yes

No

If yes, please list medication/s:

Has your child ever been hospitalized or had a mental health crisis?

Yes

No

V. Family Dynamics

If other please, Explain:

Are there family conflicts that may be affecting the child?

Yes

No

If yes, please explain:

How would you describe communication between you and your child?

Good

Fair

Needs Improvement

If other, please explain:

VII. Immediate Needs (Check all that apply)

If other, please explain:

VIII. Referral Plan (Staff Use Only)

Summary of Observations:

Recommendation / Referral:

If other:

Referral Made To (Name/Agency):

Contact Information:

Date of Referral:

Month

Day

Year

Follow-up Scheduled: Date

Month

Day

Year

IX. Consent

I certify that the information provided is true and complete. I understand that Empower Purpose may refer me to internal or external resources for my child’s well-being.

Parent/Guardian Signature:

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Date

Month

Day

Year

Staff Signature:

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Date

Month

Day

Year

Empower Purpose

Client Intake & Referral Assessment Form for Parents/Guardians

VIII. Referral Plan (Staff Use Only)

IX. Consent

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