|
Demographics
|
|
|
Client Name
|
Client DOB
|
|
Client Age
|
Client Gender
|
|
Client Phone
|
Client Email
|
|
Client Race
• • •
|
Client Ethnicity
|
|
Client Address
|
|
|
Does client have a parent or guardian?
|
|
|
Parent/Guardian Name
|
Parent/Guardian relation to client
|
|
Parent/Guardian Phone
|
Parent/Guardian Email
|
|
Previous Treatment
|
|
|
Are you currently recieving counseling/therapeutic services?
|
|
|
If yes, where are you receiving services?
|
|
|
Have you ever received therapeutic services (including inpatient or outpatient)?
|
|
|
If yes, did you find the experience beneficial?
|
|
|
If no, please explain
|
|
|
Are you currently on any psychiatric medications?
|
|
