Today's Date *
MM slash DD slash YYYY Child's Name (1) *
First Last Date of Birth *
MM slash DD slash YYYY Sex * Child's Name (2)
First Last Date of Birth
MM slash DD slash YYYY Sex Child's Name (3)
First Last Date of Birth
MM slash DD slash YYYY Sex Child(ren)'s Primary Address * Counselor you will be seeing * Choose Your Counselor Chris Bassett, LMFT Kathy Estep, LPCC Maggie Kelleher Ramona McGonagil, LPCC Micah Strouse Jen Hahn, LPC Robert Weinhauf, MA Responsible Party's Name *
First Last Relationship to Client * Mother Father Stepmother Stepfather Guardian Family Member Sibling Other Phone Number * Email *
2nd Responsible Party's Name *
First Last 2nd Responsible Party's Email
Relationship to Client Mother Father Stepmother Stepfather Guardian Family Member Sibling Other 2nd Responsible Party's Phone Number Why are you seeking counseling for your child? * Please describe the impact of the child's struggles on family and friends. Please check any boxes for stressors for your child in the past year * Define your other * Please check any current challenges. * If you said, other, please define * 3 strengths your child has: * List the 3 greatest struggles for your child and your family in regard to how therapy can help. * Has your child had similar and significant symptoms in the past? * Yes No When? * Did they recently increase? * Yes No When, and what caused it? * Prior Psychiatric Hospitalizations? * Yes No When and for what reason? * Past Counseling History for your child? * Yes No How many times was your child seen by the therapist? * Was it a positive/useful experience? * Yes No Substance Abuse History? * Yes No List what substances and when started * List treatment Locations and Dates: * Has your child experienced any physical, sexual, verbal, or emotional abuse? * Yes No Please list: * Any head/brain trauma? (concussion, asphyxia, other injury) * Yes No Please list: * Has your child ever attempted suicide? * Yes No Please explain: * Has your child ever been hospitalized for attempted suicide? * Yes No Does your child have a history of self-harm? * Yes No Is your child currently self-harming? * Yes No What is your child's height? * What is your child's weight? * Is your child currently physically healthy? * Yes No Please explain: * List any medications your child is currently taking, why, date prescribed, and any side effects/reactions. * Has your child or any of your child’s relatives suffered from major issues (i.e. cancer or diabetes) or mental health issues (depression, bipolar, substance abuse, etc.)? * Family Physician *
First Last Family Physician Phone Number * Month and year of last physical Significant Allergies: * Is your child currently in school? * Yes No Name of School your child attends: * What grade is your child in right now? *
0 = Preschool
Is your child receiving any special education services (IEP plan, 504 plan)? * Yes No Please explain: * Has your child had any behavioral struggles at school? * Yes No Please explain: * How would you describe your child's exercise? * How would you describe your child's sleep? * Is your child dieting? * Yes No How many meals does your child eat in an average day? * Do you have concerns about your child's eating patterns or habits? * Yes No Which forms of Caffeine does your child consume? * How many cups/cans per day? * How does your child identify spiritually/religiously? (i.e., Christian, atheist, Hindu, etc...): * Would you say your child has a personal relationship with Jesus Christ? * Yes No For how long? * Does your child attend a church? * Yes No Which church? And how often? * Does your child have personal concerns or questions related to God, the Christian faith, and/or the church? * Yes No Is your child open to discussing relevant matters of faith with your therapist? * Yes No Are the child’s parents currently married? * Yes No If there is shared custody, please describe the arrangement: * Please list for each sibling the following: name, date of birth, age, sex, and relevant notes. * Please describe any important family events that may have had an impact on your child’s issues (i.e. divorces, custody changes, moves, etc.). * Please describe any cultural factors (family beliefs, and values, religion, ethnicity, language, etc.) that are important to your family. * Other Relevant Notes:
Instructions to Parent or Guardian: The Following Questions ask about the early development and early and current home experiences of your child. Some
questions require that you think as far back as to the birth of your child. Your response to these questions will help your child’s clinician better understand
and care for your child. Answer each question to the best of your knowledge or memory.
What is your relationship to the child receiving care? * Was he/she born before he/she was due (premature)? * No Yes Can't Remember Don't Know Were the doctors worried about his/her medical condition immediately after he/she was born? * No Yes Can't Remember Don't Know Did he/she have to spend any time in a neonatal intensive care unit (NICU)? * No Yes Can't Remember Don't Know Could he/she walk on his/her own by the age of 18 months? * No Yes Can't Remember Don't Know Has he/she ever had a seizure? * No Yes Can't Remember Don't Know Did he/she ever lose consciousness for more than a few minutes after an accident? * No Yes Can't Remember Don't Know By the time he/she was age 2, could he/she put several words together when speaking? * No Yes Can't Remember Don't Know Could people who didn’t know him/her understand his/her speech by the time he/she reached age 4? * No Yes Can't Remember Don't Know Have you ever been concerned about his/her hearing or eyesight? * No Yes Can't Remember Don't Know By the time he/she was age 4, was he/she interested in playing with or being with other children? * No Yes Can't Remember Don't Know Was there ever a time when he/she could not live at home and someone else had to look after him/her? * No Yes Can't Remember Don't Know Has he/she ever been admitted to the hospital for a serious illness? * No Yes Can't Remember Don't Know Does anyone at home suffer from a serious health problem? * No Yes Can't Remember Don't Know Does anyone at home have a problem with depression? * No Yes Can't Remember Don't Know Does anyone at home regularly see a counselor, therapist, or other mental health professional? * No Yes Can't Remember Don't Know Does anyone at home have a problem with alcohol, drugs, or other substances? * No Yes Can't Remember Don't Know Would you say that the atmosphere at home is usually pretty calm? * No Yes Can't Remember Don't Know How often are there fights or arguments between people at home? * Less than once a month Between once a week and once a month More than once a week Most days How often does your child get criticized to his/her face by other family members when he/she is at home? * Less than once a month Between once a week and once a month More than once a week Most days Do you have any other documents you want us to see?
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