Free Child Intake Assessment Template

What is a child intake assessment?

A child intake assessment is the comprehensive clinical interview and evaluation conducted at the beginning of treatment for a child or adolescent client. Unlike an adult intake, a pediatric assessment requires gathering information from multiple sources: the child's self-report, parent or guardian report, school information, and behavioral observation across settings. Clinicians assess developmental history, family dynamics, trauma history, academic functioning, peer relationships, and behavioral or emotional concerns within the context of developmental norms. The assessment also documents parental expectations for treatment, family stressors, and protective factors. A thorough child intake establishes the baseline for treatment planning and helps clinicians identify whether concerns are age-typical or clinically significant.

What's in this template

This comprehensive child intake assessment template includes:

• Identifying Information & Reason for Referral: Child demographics, school/grade, referral source, chief concerns from child and parent perspectives
• Developmental History: Birth and pregnancy history, developmental milestones (motor, language, social), early temperament, significant life events or disruptions
• Family Structure & Dynamics: Household composition, parental mental health and substance use history, family psychiatric history, sibling relationships, custody arrangements if applicable
• Medical & Psychiatric History: Current medications, allergies, past medical conditions, family psychiatric diagnoses, previous mental health treatment
• Academic & School Functioning: Current school placement, academic performance, behavioral reports from school, special education status or accommodations needed, peer relationships and bullying history
• Social & Behavioral History: Friendship patterns, activities/interests, screen time use, sleep patterns, behavioral concerns across settings (home, school, community)
• Trauma & Adverse Experiences: History of abuse, neglect, witnessing violence, losses, or other adverse childhood experiences
• Substance Use: Exposure history, use by child or peers/family
• Strengths & Protective Factors: Child's coping skills, resilience factors, supportive adults, interests and talents
• Parent/Guardian Information: Mental health history, substance use, parenting stress, expectations for treatment, availability for parent sessions
• Assessment Observations: Clinician observations of child and parent interaction, child's affect, behavior during interview, cognitive functioning indicators
• Diagnostic Impressions & Treatment Planning: Preliminary diagnoses or concerns, case formulation considering developmental context, treatment goals and recommendations

When to use this template

Use the child intake assessment when:

• Opening treatment with a new child or adolescent client
• Conducting comprehensive diagnostic evaluations for school district or court-ordered assessments
• Documenting parental consent and understanding of treatment
• Establishing baseline functioning across developmental domains
• Identifying trauma history and behavioral triggers in a structured, comprehensive way
• Building a diagnostic formulation that integrates developmental, family, and contextual factors

This template is appropriate across settings: private practice, clinic, school-based counseling, community mental health, and residential treatment programs.

How to use the template with Scriber

Record your intake session with the child and parent together (with consent), and Scriber's AI scribe will transcribe the full interview and begin structuring information into developmental history, family dynamics, presenting concerns, and clinical observations. Rather than hand-writing pages of notes or reconstructing details from memory, you have a transcript to reference as you complete the assessment. Edit the AI-generated draft for accuracy, add observations about the parent-child interaction that Scriber might miss, refine the diagnostic formulation based on your clinical judgment, and organize the information into the assessment framework. This keeps your clinical focus on the child and family during the session while AI handles the transcription burden.

Download (free)

This template is available as a printable PDF and editable DOCX file. Customize it with your clinic name, add or remove sections based on your assessment approach, and save it as a standard form for all child intakes.

[Download PDF]

Related templates

• Geriatric Intake Assessment — Specialized intake for older adults emphasizing cognitive screening and medical complexity
• SOAP Note Template — Standard progress note format for ongoing documentation of child session work