Parent/Guardian Phone Number
Please provide the full home address(es) at which the child is currently living.
Child's Date of Birth
Child's Grade Number
How does your child perform in school academically?
How is your child's behavior while at school?
If your child has a physical or learning disability, please provide a description of this below.
If your child has previously been diagnosed with a mental health condition, please provide a description of this below.
Does your family have any specific spiritual beliefs?
Biological Father's Name
Biological Father's Date of Birth
Biological Mother's Name
Biological Mother's Date of Birth?
If any siblings are present in the child's life, please provide information about them below.
Custodial Father's Name
Custodial Father's Date of Birth
Custodial Mother's Name
Custodial Mother's Date of Birth
Who is primarily present in the child's household?
Does the father primarily work outside of the home?
If relevant, what is the father's occupation?
If relevant, what is the father's work schedule?
Does the mother primarily work outside of the home?
If relevant, what is the mother's occupation?
If relevant, what is the mother's work schedule?
If currently divorced or separated, what is the child's visitation schedule?
Please describe any history of mental illness or addiction in the immediate or extended family (depression, anxiety, bi-polar disorder, suicide attempts, alcoholism, drugs, ADHD, schizophrenia, etc.):
If the child has witnessed any form of domestic violence, please describe this situation below.
How is the child disciplined?
Please list each method and frequency of use
If the child has been verbally abused, please describe this situation below.
If the child has been physically abused, please describe this situation below.
If the child has been sexually abused, please describe this situation below.
Has the child experienced any other stressors or traumas?
Please select any symptoms from the below list that the child has displayed
Acts out sexually
Has unusual sexual knowledge
Homicidal thoughts or actions
Drug or alcohol use
Lack of empathy
Lack of motivation
Low impulse control
Plays out violation themes
Plays out sexual themes
If any of the above symptoms were applicable to the child, please specify the frequency in which the symptoms were observed.
If the child has displayed any somatic symptoms recently, such as headaches or stomachaches, please list them below.
How does the child handle anger?
If the child has experienced any significant loss, please explain the situation below.
What do you view as the child's major strengths and positive traits?
What are the child's hobbies?
Breifly describe your goals for the child's therapy.
Please list any information you deem to be important for the therapist to know.