Client Information Except in cases of child/elder abuse or immediate danger to yourself/others, all information provided will be kept strictly confidential and released only in accordance with professional ethics and applicable law. Date Referred by Client Name / / M F Birth Date Parent Name (s) / / M F Birth Date / / M F Birth Date / / M F Birth Date / / M F Birth Date Sibling’s names/ages Others living in your home Address Street Apt. # City Zip Home phone Okay to leave message? Yes No Cell phone Email School Grade: School Performance (academic/behavioral): Excellent / Good / Fair / Poor School concerns: Current Concerns Check the areas which apply Depression Career Spiritual issues Anxiety/Stress School Trauma Relationships Grief Finances Eating issues Anger Health Life Transitions Abuse Insecurity Substance abuse Family Sexuality Divorce Parenting Suicidal thoughts What are the major concerns for which you’re seeking counseling for child? On a scale of 1 (mild) to 5 (severe), how would you rate child’s issues? 1 2 3 4 5 How long have these issues been a concern?
Client Information Except in cases of child/elder abuse or immediate danger to yourself/others, all information provided will be kept strictly confidential and released only in accordance with professional ethics and applicable law. Date Referred by Client Name M F Birth Date / / Parent Name (s) M F Birth Date / / M F Birth Date / / M F Birth Date / / M F Birth Date / / Sibling’s names/ages Others living in your home Address Street Apt. # City Zip Home phone Okay to leave message? Yes No Cell phone Email School Grade: School Performance (academic/behavioral): Excellent / Good / Fair / Poor School concerns: Current Concerns Check the areas which apply Depression Anxiety/Stress Relationships Eating issues Life Transitions Substance abuse Divorce Career School Grief Anger Abuse Family Parenting Spiritual issues Trauma Finances Health Insecurity Sexuality Suicidal thoughts What are the major concerns for which you’re seeking counseling for child? On a scale of 1 (mild) to 5 (severe), how would you rate child’s issues? 1 2 3 4 5 How long have these issues been a concern?