Tipton Intake Form
Student Name
City
State
Zip
Age
Date Of Birth
Height
Weight
Parent First & Last Name
Best Number To Contact
Best Email To Contact
Poor Grades? Explain
Truancy From School? Explain
Fighting In School? Explain
School Suspensions? Explain
Lack Of Interest In Activities? Explain
Medication? Include Medication, Reasons, How
Long On Drug
Suicide Attempts (Pleas Be Detailed)
Suicide When
Suicide How
Was Hospitalization Required?
Victim Of Abuse? Explain
Perpetrator Of Abuse? Explain
Number Of Previous Placements
Type Of Placement. Explain
Length Of Stay In Placement
Defiant? Describe
Disrespectful? Describe
Lack Of Regard For Rules: Describe
Change In Behavior? Describe
Breaking Curfew? Describe
Runs Away? Describe
Aggression Problems? Describe
Pushing?
Punching?
Verbal?
Weapons?
Frequency?
Change In Friends? Describe
Sexually Active? Describe
Substance Abuse Problems? Describe
Type Of Drug
Frequency
Age Of Onset
Drinking?
Frequency
Age Of Onset
Gang Involvement?
Was Law Enforcement Involved? Describe
Charges?
Pick Up With Formal Charges. Describe
Psychological History. Describe In Detail
Age Of Diagnosis
Fighting In School? Describe
High Frequency?
Aggression at Home? Describe
Punching?
Weapons?
High Frequency?
Psychological Diagnosis?
Bi Polar?
Borderline Personality?
Autism?
Suicide Attempts In Last 6 Months? Describe
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