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Child/Adolescent Name
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Date of Birth
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Preferred Name:
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Home Address:
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Current Age
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Client Race
• • •
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Client Address
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Client Ethnicity
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Client Email
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Client Gender
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Preferred Pronouns:
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Sexuality:
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Emergency Contact Name:
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Emergency Contact Phone:
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Primary Care Physician
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Physician's Phone Number:
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Specialists
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Specialist Contact Phone Number:
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Client Current Medications
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Medication Instruction
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Does client have a parent or guardian?
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Parent/Guardian Name
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Parent/Guardian Name
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Parent/Guardian Email
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Parent/Guardian Email
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Parent/Guardian relation to client
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Parent/Guardian relation to client
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Parent/Guardian Phone
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Parent/Guardian Phone
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Client Phone
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Why are you seeking therapy?
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2. Name / ages of all people living in the home.
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What strengths and abilities does client possess?
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Present Symptoms/Information
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Please describe your current complaint, symptoms and behaviors, in your own words:
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How long have you experienced these symptoms?
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What stressors if any have contributed to this?
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Describe coping skills used
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Has the client experienced any of the following stressful events within the past 12 months:
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Explained all checked items:
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BHR; check all words that describe what you are experiencing:
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Explained all checked items:
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SOMATIC COMPLAINT: check all words that describe what you are experiencing:
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Explained all checked items:
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ANX: check all words that describe what you are experiencing:
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Explained all checked items:
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DPR:check all words that describe what you are experiencing:
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Explained all checked items:
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PSY:check all words that describe what you are experiencing:
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Explained all checked items:
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TRAUMA:check all words that describe what you are experiencing:
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Explained all checked items:
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ABUSE:check all words that describe what you are experiencing:
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Explained all checked items:
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EDUCATIONAL/VOCATIONAL HISTORY
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Current School Attended
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Grade
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Describe the client’s behaviors at school or work and abilities/difficulties in getting along with others:
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Special Education /Learning Disability Comments
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In school did/do you have an IEP
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In school did/do you have a 504?
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Learning Disability daignosed
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Previous Treatment
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Have you ever received therapeutic services (including inpatient or outpatient)?
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If yes, with whom?
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Are you currently recieving counseling/therapeutic services?
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If yes, with whom?
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If yes, did you find the experience beneficial?
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If no, please explain
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Are you currently on any psychiatric medications?
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SOCIAL HISTORY
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Who is your Support System?:
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In what social/recreational activities does the client engage in?
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Are there any social/recreational activities or hobbies the client enjoys with friends/family?
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If yes, explain:
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CLIENT'S DEVELOPMENTAL HISTORY
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Development
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Development Explain
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Sexual History
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Has client reached puberty?
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Client First Sexual Encounter Ag
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Was this consensual
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Is client sexually active
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Any safety issue?
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Has client engaged in any inappropriate sexual behavior?
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If YES, explain:
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TRAUMA & ABUSE HISTORY
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Physical
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Describe - Duration
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Emotional
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Describe - Duration
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Sexual
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Describe - Duration
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Neglect
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Describe- Nature of Relationship
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Describe - Severity of Abuse
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Describe - Duration
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Has the client ever feared that she/he will be injured or killed?
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Has the client ever feared that a family member or anyone else will be injured or killed?
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Seen someone injured or die
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Die or Injured Comments
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Substance Abuse History
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Does client have a current/ past history of substance abuse?
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description:
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Has the client had any alcohol or substance abuse treatment to include:
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description:
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Have there been any legal/other consequences of the client’s substance abuse?
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If yes, explain:
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Does the clients family have a current/past history of alcohol or substance abuse?
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If yes, describe identifying family member(s), roles(s) and details including treatment outcomes:
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Have there been any legal/other consequences of family member’s substance abuse?
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If yes, describe:
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SPIRITUAL HISTORY
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Spiritual/Cultural Belief System
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Practice by Family
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LEGAL HISTORY (Explain if Necess
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Current Legal Problems
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If yes, Describe:
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Has Client ever Gone to court or appeared before a judge for a legal infraction?
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If yes, explain:
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Has Client ever been on parole/probation or under court supervision?
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Has client ever been remanded to dentition center or county/state training school?
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If yes, with whom?
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Has Client ever been detained or arrested?
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Childhood/Relational Family
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Clients relationship with Parent/Guardian Figures:
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Client Raised by:
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Client's Parents Married
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Client's Place of Birth
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Client's # of Siblings(Name(s)/A
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Siblings (Name(s) and Age(s)
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Client's Family Biological/Adopt
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Client Adopted Age
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3. What stressors can you identify in your current families living arrangement/relationships?
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If yes, explain:
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Client's # of Moves in Lifetime
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Are there any child custody issues involving you or your family?
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Does you/your family have any CPS involvement?
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If yes, explain:
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Any family information/history you may find helpful:
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Referral Source
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Referral Source:
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