Health Questionnaire (HQ) Ages 0-10

Thank you for choosing Northland Counseling Center! Please fill out the form below and once completed please make sure to also fill out Minor Registration Form, SDQ Parent Form, Supervision Form & Authorization to treat a Minor. Once completed an intake staff will contacting you.

Age 0-10 Health Questionnaire NEW

Minor Pre-Intake Questionnaire
To be complete by a Parent / Guardian
Location of Services:
- Grand Rapids
- Hibbing
- Aitkin
- International Falls
Today's date
MM slash DD slash YYYY
Email
Child's Name
First Middle Last
Child's Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Child's Phone (Phone number where child primarily resides)
May we leave a message?
- Yes
- No
May we text you?
- Yes
- No
Email (if appointments are via telehealth, please list email that information will be sent to)
May we email you?
- Yes
- No
Gender:
- Male
- Female
- Non-Binary
Date of Birth
MM slash DD slash YYYY
Age
Social Security Number
Race:
- Asain
- Black / African American
- Native Hawaiian
- White
- American Indian/Alaskan Native
- Other
If you identify as Native American / Alaskan Native; are you a currently an enrolled tribal member?
- Yes
- No
- Unsure
If you identify as Native American / Alaskan Native, please indicate your Tribal Affiliation:
If you identified as 'other' for race, please indicate race below:
Ethnicity:
- Hispanic / Latino, if yes please see next question
- No
If Hispanic / Latino please select:
- Central American
- Cuban
- Dominican
- Puerto Rican
- South American
Hair Color:
Length:
- Short
- Medium
- Long
Eye Color
Do you wear:
- Eye Glasses (primarily)
- Contacts (primarily)
- Both
Who retains custody:
- Biological Parents
- Biological Mother
- Biological Father
- Social Services
Name of who is completing this form:
First Last
Relationship to the client:
Parent / Guardian Information
Primary Parent Information
Primary Parent / Guardian (Primary Point of Contact)
First Last
Primary Parent / Guardian Date of Birth
MM slash DD slash YYYY
Do you have Custody of the child being registered:
- No
- Yes, Full Custody
- Yes, Legal Only
- Yes, Physical Only
Marital Status
- Married to child’s biological father / father
- Married to child’s biological mother / mother
- Divorced
- Separated
- Widowed
- Living with significant other (boyfriend/girlfriend/fiancé)
- Single (never married)
Primary Parent / Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone
Work Phone
Secondary Parent Information
Secondary Parent / Guardian
First Last
Secondary Parent / Guardian Date of Birth
MM slash DD slash YYYY
Do you have Custody of the child being registered:
- No
- Yes, Full Custody
- Yes, Legal Only
- Yes, Physical Only
What is your relationship to the child?
- Mother
- Father
- Legal Gaurdian
- Yes, Physical Only
Marital Status
- Married to child’s biological father / father
- Married to child’s biological mother / mother
- Divorced
- Separated
- Widowed
- Living with significant other (boyfriend/girlfriend/fiancé)
- Single (never married)
Secondary Parent / Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone
Work Phone
Other Guardian, If applicable
Other Guardian
First Last
Other Guardian Date of Birth
MM slash DD slash YYYY
Do you have Custody of the child being registered:
- No
- Yes, Full Custody
- Yes, Legal Only
- Yes, Physical Only
Marital Status
- Married to child’s biological father / father
- Married to child’s biological mother / mother
- Divorced
- Separated
- Widowed
- Living with significant other (boyfriend/girlfriend/fiancé)
- Single (never married)
Other Guardian Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Primary Phone
Work Phone
County of Responsibility
Reason for your visit
Tell us who referred you:
- Self-referred
- Referred by Health Care Provider / Mental Health Provider
- Court
- Chemical Dependency / Drug Court
- Employment Requirement
Please explain the reason(s) you are seeking mental health services:
What services are you hoping to receive from Northland Counseling Center :
- Diagnostic Assessment Only
- Individual Therapy
- Family Counseling
- Children’s Case Management**
- Testing (Ex. ADHD)
- Kiesler Wellness Center *
- Hardwig House **
- CTSS **
- BHH
- Children’s Day Treatment *
- Medication Management
{(*) Grand Rapids Only} {(**) I-Falls Only}
Current Life Situation
Where does the child live:
- Apartment
- House
- Residential Facility
- Homelesss
Who do you reside with:
- Parents
- Siblings
- Foster Parents
- Group Home
- Friends
Please list Name, Age and Relationship of those who you reside with:
How would you describe your living situation:
- Excellent
- Good
- Okay
- Poor
Income / Employment Information
Current Source of Income
- Wages
- Social Security
- Pension
- MFIP
- Child Support
For Parent / Guardian
Employment
- Full-time
- Part-time
- Seasonal
- Self-Employed
- Disabled
- Retired
- Volunteer
For Parent / Guardian
Employers Name:
Occupation:
Education History
Education:
- GED
- High School Diploma
- Vocational Certificate
- Some College
- College Graduate
- Post Graduate
- Did not complete school
- Currently enrolled
Highest grade completed if you did not complete high school:
If currently enrolled, what grade?
If currently enrolled, what school are you attending:
Special Education Services:
- No
- Yes, please tell us more below
What type of Special Education Services are you receiving:
Barriers to learning or Past School Testing:
- Speech
- Hearing
- Reading
- Writing
- Concentration
- Attention
- Conflict with Peers
- Conflict with Teachers
- None
Additional Comment about Educational History:
Early Childhood Information
Early Childhood/Childhood Development- Any concerns with development, nutrition, and social concerns:
Please indicate child's developmental information and indicate any major delays your child may have had:
- Speech
- Hearing
- Reading
- Writing
- Child is under the age of one
- Speech
- Sitting, crawling, walking
- Toilet Training
- Sleeping through the night
At what age did the child begin to talk:
At what age did the child begin to sit, crawl and walk:
At what age did the child begin to use the toilet independently:
At what age did the child begin to sleep through the night:
Was it a normal birth:
- Yes
- No
List any complications or birth defects, etc:
Were early childhood milestones met on time?
- Yes
- No
If no, please list any delays:
List any special needs in childhood:
Symptoms / Relevant History
Child being Regiestered:
Have you ever received out-patient mental health services:
- Yes, please describe below
- No
Please list agency / dates of previous mental health services:
Have you seen a Psychiatrist or Nurse Practitioner for medication managements:
- Yes, please describe below
- No
Please list agency / dates of previous mental health services:
Please let us know what symptoms your child may be experiencing:
- Anxiety
- Worry Thoughts
- Racing heart
- Depressed mood
- Irritable mood
- Sleeping too much
- Isolating
- Concentration
- Attention
- Inability to follow instructions
- Nightmares
- Vomiting
- Restricted food intake
- Difficulties with relationships
- History of Abuse (physical, mental, sexual)
- Impulsivity
- Intense Anger
- Experienced a traumatic event
- Difficulty with authority figures
Substance or Alcohol Abuse History
Have you participated in a substance abuse treatment program
- Yes, please describe below
- No
Please list agency / dates of previous mental health services:
Do you feel you have a problem with substances and/or alcohol:
- Yes, please describe below
- No
Child / Alcohol : Please indicate how much / how often use occurs
Parent / Alcohol : Please indicate how much / how often use occurs
Child / Tobacco : Please indicate how much / how often use occurs / type used
Adult / Tobacco : Please indicate how much / how often use occurs / type used
Adult / Caffeine : Please indicate how much / how often use occurs
Child / Marijuana : Please indicate how much / how often use occurs
Adult / Marijuana : Please indicate how much / how often use occurs
Child / Other Substances : Please indicate how much / how often use occurs
Adult / Other Substances : Please indicate how much / how often use occurs
Child / Non-Medical use of prescribed or over the counter drugs : Please indicate how much / how often use occurs
Adult / Non-Medical use of prescribed or over the counter drugs : Please indicate how much / how often use occurs
Is there any family history of substance and/or alcohol abuse / dependence?
- Yes, please describe below
- No
If yes, please describe:
Medical History
For child being registered
List current / past medical conditions:
Have you had your thyroid checked?
- Yes, please provide date below
- No
- Unknown
- Never been Checked
- Yes, Normal
- Yes, Hypothyroidism
- Yes, Hyperthyroidism
If yes, please provide date of thyroid check if known:
Any family members with a thyroid condition?
- Yes, please indicate who and what type of known
- No
- Unknown
If yes, please indicate family member and what type if known:
Primary Care Clinic or Hospital
Primary Care Physician
First Last
Please state the last appointment with a Primary Care Physician
MM slash DD slash YYYY
If dates is unknown, please indicate approximate date
- Within the past month
- Within six months
- Over one year
- Over 5 years
Pharmacy
Are you currently taking and medicatons? If yes, please list name of medications and dose.
Do you have any surgical history? If yes, please explain.
Medication Allergies
- Yes
- No
List Medication Allergies
Other Allergies
- Yes
- No
List Other Allergies
Medication side effects
- Yes
- No
List the medication and the side effect
Supplemental Medicinal Treatment (St. Johns wort, herbs, vitamins)
- Yes
- No
Types of medicinal treatment used
Are you currently disabled?
- Yes
- No
If you consider yourself disabled, please explain.
Head/Brain injuries, seizure, stroke, concussion or loss of consciousness?
- Yes
- No
If you have had a history of head injury, please explain.
Significant medical problems of immediate family members and/or medical problems that run on your side of extended family, if so please indicate:
For Northland Counseling Center, Inc to serve you better:
Please list, to the best of your knowledge, any family members that currently work for Northland Counseling Center, Inc to avoid a conflict of interest for your provider:
Please list, to the best of your knowledge, any people with whom you have had a significant relationship with that currently or previously attend/attended therapy at Northland Counseling Center, Inc to avoid a conflict of interest for your provider.
By checking this box you are acknowledging that all information presented is true to the best of your knowledge.
I agree that all information is true and correct

Age 0-10 Health Questionnaire NEW

Minor Pre-Intake Questionnaire

Parent / Guardian Information

Reason for your visit

Current Life Situation

Income / Employment Information

Education History

Early Childhood Information

Symptoms / Relevant History

Substance or Alcohol Abuse History

Medical History

For Northland Counseling Center, Inc to serve you better:

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