Adolescent Intake Form

Thank you for your interest in our Adolescent support groups. The purpose of this screening is to determine if re:MIND services are a good fit for your adolescent's needs. The group is a safe place for adolescents to talk about coping skills, process feelings, and provide support to their peers. These groups are led by a trained facilitator and are professionally monitored and managed. Our services are best utilized as only one part of an overall wellness plan which may include therapy, medication, counseling, etc.

Please complete this form to the best of your ability based on your adolesecent's behavior in the most recent month.

Today's Date

Adolescent Demographics

Adolescent Name

Adolescent Date of Birth

Adolescent Zip Code

Grade Level

Name of School Attending

Gender

Does adolescent have siblings?

If yes, how many siblings?

Do sibilings live with adolescent?

Diagnosis and Treatment

What brought you to seek our services?

Describe briefly your main concern about the adolescent

Does adolescent have a diagnosis of mental disorder?

If yes, please specify.

Depression

Bipolar Disorder

Other

Date of Diagnosis (Month/Year)

Is adolescent in talk therapy?

If yes in therapy, how long has adolescent been in therapy? How often are sessions? Has there been a lapse?

Is adolescent currently taking medication for mental disorder?

If yes to medication, how long has adolescent been taking medication? Has there been a lapse? Do you think it is helping?

Has the adolescent had any history of suicidal thoughts?

If yes, when did this occur? How did you respond to suicidal thoughts? What actions did you take?

Has the adolescent had any suicide attempts?

If yes, when was suicide attempt?

Has the adolescent ever been hospitalized for mental disorder?

If yes to hospitalization, when did this occur? What were the circumstances/result?

Have you had any concerns about alcohol or drug use for your adolescent?

If yes, what are your concerns? Which substances is your adolescent using? Any treatment sought?

Is/has adolescent been involved with the criminal justice system?

If yes to criminal justice system, When? What was the charge?

Signs and Symptoms

On a scale of 1-5, (1 being none of the time and 5 being all the time), rate your adolescent on these items in the last month:

Inflated self-esteem

Major increase or decrease in need for sleep

More or less talkative than usual:

Distracted

Agitation (anger, irritable)

Feeling sad

Loss of interest in previously enjoyed activities

Significant weight loss/weight gain

Restlessness

Noticeable lack of energy

Indecisiveness, nearly every day

Hallucinations/Delusions

Thoughts of death of suicide

If your adolescent has thoughts about death or suicide, please explain.

Isolation

Additional comments regarding signs or symptoms.

Peers, School, Support Group

Explain your adolescent's relationships with peers/adolescents their age.

Relationship with peers/challenges at school.

Is adolescent currently receiving school interventions? Ex: special Ed, behavior modification, or IEP (individualized education plan)?

If yes to school services, which ones and do you feel they are helping adolescent?

Biggest concern about adolescent?

Biggest perceived challenge from adolescent perspective?

Have you spoken with your adolescent about attending a peer support group? Are they interested?

What results do you hope to see as a result of adolescent attending support group?

What changes do you hope to see overall in the adolescent?

What is adolescents hope for themselves?

Parent/Legal Guardian Questions

Parent/Legal Guardian Full Name

Parent/Legal Guardian Phone

What type of phone number?

Parent/Legal Guardian Email (Enter twice to verify)

I would like to receive emails with group updates (closing, weather, holidays, etc).

I would like to receive the re:MIND E-Newsletter.

How did you hear about re:MIND's adolescent groups?

Are you the parent or legal guardian of the adolescent?

Are you the primary caretaker?

If no, Name of Primary Caretaker?

Other adults in the home?

Additional caretakers?

Emergency Contact (other than legal guardian)

Emergency Contact Name (other than legal guardian):

List Emergency contact other than legal guardian if you are unavailable

Emergency Contact Phone (other than legal guardian)

Emergency Contact Relationship to Adolescent

Additional Contact Persons

What happens next

You will be redirected to the Parent/Guardian and Adolescent Consent Form. The consent form is required for us to move forward with the application. A Program staff will review application (this intake form and the re:MIND electronic consent). The parent/legal guardian will then be notified by e-mail within 5 business days of initial screening. Once the adolesent is accepted, group logistics will be provided. For the adolescent to attend group, the parent/legal guardian must be present in the building during group time. The adolescent and parent/legal guardian must also complete the weekly sign in sheet for the in person group.

Adolescent Intake Form

Adolescent Demographics

Diagnosis and Treatment

Signs and Symptoms

Peers, School, Support Group

Parent/Legal Guardian Questions

Emergency Contact (other than legal guardian)

What happens next

Find a Support Group

Search Groups by Zip Code

Map of Support Groups

About Our Groups

re:MIND Brochures