Name of person completing this form:
*
First Name
Last Name
Email
*
Your relation to the child:
Phone Number
(###)
###
####
Child’s name:
Child's Birth Date:
MM
DD
YYYY
Child's Ethnicity:
Child's Religion:
Child's Sex / Gender:
Child's Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Who does your child live with?
Name of child's school:
Child's grade/year in school:
School program:
What are you child's typical grades?
How did you find this therapist?
What are the reasons for your child's visit?
Kindly explain the reason of your rating above.
Kindly explain further your rating above.
When did these problems start? What was going on in your child’s life at that time?
Please list any medications your child currently takes, and what they are taken for:
Just put none if this is not applicable to your child
Name of Family Doctor
First Name
Last Name
Phone
(###)
###
####
When was your child's last checkup?
MM
DD
YYYY
What were the results?
Name of Psychiatrist:
First Name
Last Name
Phone
(###)
###
####
When was their last appointment?
MM
DD
YYYY
What were the results?
Has your child ever been hospitalized for psychological or psychiatric reasons?
If Yes, please describe when, where, and for what reason.
Please tell us about any other mental health professionals your child has consulted with in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment):
Please describe your child’s current habits in each of the following areas: Smoking, Drinking, Drug Use, TV Use, Internet Use, Video game Use, Caffeine Intake, Exercise, Eating, Sleeping, Fun and Relaxation, Chores and Responsibility.
Please describe your child’s relationships with each of the following people, if applicable: Biological Mother, Biological Father, Step-Parents, Legal Guardians, Siblings, Extended Family, Your Children, Friends, Romantic Partner(s), Colleagues, Classmates, Total number of close supportive relationships:
Please check any significant or stressful life events that your child has been experiencing
If you checked any of the above, please describe more about it below:
What are your child’s positive qualities and skills? What do you like about yourchild? What qualities have helped your child to succeed at overcoming difficulties in the past?
Please tell us about your child’s interests (sports, hobbies, talents, etc.)
Does your child agree that the problem that she or he is seeking help for is problematic?
What are some goals for your child’s therapy? What would you like him/her to achieve by attending therapy?
Date completed this form
MM
DD
YYYY
