Champion Psychological Services, LLC
P.O. Box 2623 Mercerville, NJ 08619
Minor Intake Form
1. Name: Sex: Age: DOB
2. Natural Child Yes / No If adopted, at what age Foster since
3. Parent’s Names (include step-parents, foster parents, etc.)
4. Comments about custody and visitation (if applicable):
5. Primary reason you are concerned about your child?
6. Parent's Email
1. Present School: Grade: Teacher:
2. Has child ever repeated any grade?
3. Is child in special education services? No Yes, what kind?
4. Please describe academic or other problems your child has had in school
Mother used during pregnancy: alcoholdrugscigarettes
Delivery: NormalBreechCesareanTransectionalFull-termPrematureif premature, number of weeks
Problems at birth: (for example: infant given oxygen, blood transfusion, placed in an Incubator, etc.)
2. Developmental History
State approximate age when child did the following: