INDEPENDENCE FAMILY THERAPY ENTERPRISES, CORP.

IN-TAKE

YOUTH NAME:	DATE:

STREET ADDRESS:	CITY:	STATE:	ZIP CODE:

TELEPHONE NUMBERS: HOME:(	)	WORK: (	)	PARENT/GUARDIAN:

REFERRAL SOURCE	INSURANCE:

EMERGENCY CONTACT:	PHONE #:

COMPOSITION OF FAMILY

NAME:	AGE	RELATIONSHIP TO CHILD	EMPLOYMENT OR GRADE	AT HOME, OR, WHEREABOUTS
PRESENTING PROBLEM:
HISTORY OF PRESENTING PROBLEM:
FAMILY HISTORY:
Previous Placements/Services	Length of Stay
PHYSICAL/SEXUAL/EMOTIONAL ABUSE (PAST AND CURRENT):
DRUG AND ALCOHOL ABUSE (PAST AND CURRENT):
EDUCATIONAL PLACEMENT/HISTORY:
HEALTH HISTORY:
APPEARANCE:	AFFECT/MOOD:
THOUGHT PROCESSES:	HALLUCINATIONS:
ENURESIS/ENCOPRESIS:
SUICIDAL IDEATION/ATTEMPTS (PAST AND CURRENT):
FIRESETTING (PAST AND CURRENT):
INDIVIDUAL AND FAMILY ASSESSMENT:

Therapist/BA	Date: