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Child & Adolescent

Parenting or caring for a young person in today’s world can feel overwhelming at times. Between peer pressure, changing family dynamics, grief and loss, the challenges and navigation of adolescence, and the pressures to achieve — it’s easy to feel uncertain about how best to guide and support them.

Even when there aren’t any immediate concerns, mentorship and emotional support can play a vital role in shaping a young man’s character, building his confidence, and helping him develop greater self-awareness.

We invite you to take this meaningful step — one that nurtures resilience, empathy, and emotional strength as he grows from boyhood into manhood.

MASC Minor / Adolescent Intake Form

Parents/guardians, please help complete this form. Children are encouraged to answer in their own words where indicated.

Child / Adolescent

Full name Date of birth Gender (optional)

Parent / Guardian Information

Mother / Guardian full name Mother / Guardian date of birth Mother / Guardian home address Mother / Guardian phone Mother / Guardian email Father / Guardian full name Father / Guardian date of birth Father / Guardian home address Father / Guardian phone Father / Guardian email

Legal Information

Legal issues affecting the child (current or past) Who has legal/physical custody? Upload custody/legal documentation (optional)

Insurance Information

Insurance provider & name of insured Certificate #

Main Concerns

Main reason for seeking counselling (child may answer in own words)

Goal 1 Goal 2

Health & Mental Health History

Pediatrician / Family Doctor Previous counselling or therapy? If yes, when and with whom? Hospitalisations for mental or emotional health? If yes, when and why? Current medication? If yes, what and why?

Learning difficulties or need for special accommodations?

YesNo If yes, please provide details (documentation may be requested) Upload supporting documentation (optional)

Substance Use

Alcohol — how often / how much? Vaping or marijuana — how often / how much? Other drugs used? Which and how often? Previous treatment for substance use? Where?

Current Concerns (check all that apply)

AngerBehavioural ProblemsImpulsivenessGang InvolvementDepressionSelf-HarmWithdrawnSelf-BlameAggressionAbandonmentMood SwingsPast TraumaPeer ProblemsUnhelpful ThoughtsAnxietyIsolationSleeplessnessHarming OthersOther If “Other”, please specify

Family History

Parents’ relationship Do you think their relationship is good? (child may answer)

If parents live apart: Who do you primarily live with? How often do you see Dad? How often do you see Mom?

Have you ever experienced abuse or neglect?

YesNo

If yes, check all that apply

PhysicalVerbalSexualNeglectEmotionalWitnessing Violence

Relationships

With my mother / guardian With my father / guardian With my siblings (how many, and how you get along)

Family Mental Health & Medical History

Diagnosed mental health conditions in the family Family hospitalisations for mental/emotional health Family history of suicide attempts or deaths Substance or alcohol misuse in the family Major medical conditions affecting stress/emotional health History of violence, trauma, or domestic violence

Family Concerns (check any that apply)

FightingFeeling distantLoss of funLack of honestyMedical concernsEducation challengesFinancial challengesDeath of a family memberInadequate housing / feeling unsafeAlcohol or drug useTraumaInfidelity (couple)Divorce / separationIssues regarding remarriageBirth of a childJob change or dissatisfactionOther If “Other”, please explain

Peer & Social Life

How do you consider yourself socially? Are you happy with the amount of friends you have? Have you ever been bullied? Have you ever bullied others? Are your parents/guardians happy with your friends? Activities (sports, clubs, music, etc.)

School History

Do you like school? Do you attend regularly? Current grades Do you feel you are doing your best in school?

Internet & Technology

Concerns about internet/social media use (Instagram, Snapchat, TikTok, texting, etc.)? If yes, please explain

Final Questions

Anything else you’d like us to know? How did you hear about us?

For Child / Adolescent Only (Optional)

Parents: please give your child space to answer these in their own words. This section is just between your child and their counsellor.

1) Why do you think you are coming to counselling? 2) If counselling could help you with one thing, what would it be? 3) What makes you feel happy or safe? 4) What makes you feel sad, worried, or angry? 5) Who do you feel closest to in your family? 6) Do you ever feel left out, picked on, or bullied? 7) Do you have a friend or adult you trust when you need help? 8) Is there something you wish your parents or family understood about you? 9) Anything else you’d like your counsellor to know?

All information will be reviewed with you during your first session.

But I must explain to you how all this mistaken idea of denouncing pleasure and praising pain was born