Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )

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Please fill out the entire form, answering the questions as they pertain to your child or teen. Leave blank any that are unclear or that you want additional clarification on. Thank you. General Information: Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( ) Address: City: State: Zip: Employer: Work phone: ( ) Email: Parent s Name #2: Home home: ( ) Cell: ( ) Address: City: State: Zip: Employer: Work phone: ( ) Email: Who will be responsible for making/keeping appointments? Ok to leave phone message? Which number? Ok to send mail? Emergency contact/relation: Phone: ( ) Alt phone:( ) Child s primary care provider: Clinic name/phone: Allergies: Medical conditions: Grade level and school: Interests/hobbies: I was referred by: Insurance Information: Insurance Provider: Subscriber s name: Subscriber s birthdate: / / Subscriber s address (if different than above): Name of employer: Insurance phone: ( ) Address: ID#: Group #:

**A copy of your card will be made if you would like your insurance to be billed for reimbursement. Therapy Goals and History: What brings you and your child in? What would you like to be different? Who supports you and your family in your decision to begin counseling? Has your child seen a therapist before? When? From 1-10, rate previous experiences: Name(s) of previous therapist(s): Phone: ( ) What helped? What didn t? Family History: Who lives in the home? Names, ages and relationship. Who are the significant adult figures in your child s life? Describe significant changes/transitions in your child s life and the age that they occurred. For example, divorce, moves, change in schools, death/loss, removal from parents care. If parents are divorced or separated, what are the current custody and visitation arrangements?

Symptom Checklist: Check 0, if you are not currently concerned about the symptom; 1, if it is a mild concern; 2, if it is a moderate concern and 3, if it is a serious concern. Symptom 0 1 2 3 Symptom 0 1 2 3 Depressed mood/sadness Sleep Trouble Grief and loss Fatigue/low energy Loss of appetite Weight gain or loss Apathy or lack of motivation Suicidal thoughts or attempts Symptom 0 1 2 3 Symptom 0 1 2 3 Substance abuse Feelings of worthlessness Headaches/stomach pain Social isolation Guilt/Shame Poor attention or focus Hyperactivity Self-esteem issues Mood swings Unusual or racing thoughts Anger Aggression/violence Anxiety or worry Panic attacks Phobias Obsessions Compulsive behavior Victim of abuse or trauma Feeling detached or distant Hearing or seeing things Self-harming or cutting Difficulty making/keeping friends Exposure to domestic violence Legal trouble Learning difficulties Tolieting issues Behavior concerns at school Tantrums/fits Poor grooming Irritability Binging/purging Anorexia Tearfulness Chronic medical condition Defiance/oppositional behavior Victim of a crime Nightmares Other: Other: Other: Psychiatric Treatment History: Has your child seen a psychiatrist in the past? Yes No Name/phone: Is he or she currently seeing a psychiatrist? Yes No Name/phone: Current medications and supplements, along with dosage:

Has your child been hospitalized for emotional, psychological or substance use issues? If yes, when and for how long: Location/Facility name: Has anyone else in your family had similar psychological or emotional difficulties and/or concerns? Please explain. Developmental History: Were there any complications with the pregnancy and delivery of your child? If yes, explain. Have you or anyone else had concerns about your child s development? If yes, explain. Have you or anyone else had concerns about your child s social development? If yes, explain. Have you or anyone else had concerns about the intellectual or academic functioning of your child? If yes, explain.

Substance Use Inventory: Please indicate if your child has used or is currently using the following substances. Please list other family members who have used or are currently using. Age of child s first use When last used Current frequency and amount Previous treatment Alcohol Marijuana/ Hashish Meth/ Speed Cocaine/ Crack Heroin Family members with past or current use issues. Age of child s first use When last used Current frequency and amount Previous treatment Prescription drugs Inhalants Ecstasy/ Molly Mushrooms Caffeine Nicotine Other: Other: Family members with past or current use issues. Cultural and Spiritual History: Cultural identity: Spiritual identity: Importance of spirituality/religion: Low Med High Is your child or family currently active in your community? If so, describe: Does your child or family currently engage in spiritual activities? If so, describe:

Socio-Economic History: Living Situation: Housing adequate Homeless Housing overcrowded Housing dangerous / deteriorating Living companions unstable Family Finacial Situation: No current financial stress Large debt Low income Impulse spending Relationship conflict over money Parental Legal History: No legal problems Parole / probation Arrest(s) not substance related Arrest(s) substance related Jail / Prison time Employment: Employed & Satisfied Employed but Dissatisfied Unemployed Conflicts at work Unstable work history Disabled Student / underage Family s Social Support System: Supportive network of friends and family Few friends New to the area No friends Geographically or emotionally distant from family Last legal difficulty:

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