Child Information Gathering Form

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Date *

Name *

First

Last

DOB *

Age: *

Gender *

• Male
• Female

Birthplace: *

Address *

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Name of parent(s)/guardian(s) who have legal custody of child (All legal parent(s)/guardian(s) MUST provide written consent for services): *

* Address if parent/guardian lives in another residence:

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone Number(s): *

Is it ok to leave a voicemail? *

• Yes
• No

Is it ok to send you something in the mail? *

• Yes
• No

How were you introduced to us? *

If you found us online what words did you search to find us? *

How Have We Come to Meet?

What are the 3 biggest concerns you have for your child right now? How long have each been going one? Put them in order of importance: *

What do you think your child would say their biggest concern(s) is/are? *

What solutions (helpful or unhelpful) have you tried to resolve the above concerns? *

Have you or your child(ren) had therapy in the past? If so, please provide treatment providers names, dates of service, what your child was seen for, and results. *

Change is Coming...

What are your expectations from therapy and the therapist? *

If you had a crystal ball and were able to look into the future you will say therapy has been worth it because (list concrete changes you would like to see): *

What other things would you like to see change in your life and your family’s life? *

Do you foresee any obstacles to achieving your goals/changes? *

How long will therapy need to last to achieve the changes/goals you want? Write down a target date: *

List 5 strengths about your child, give examples of each: *

Has your child ever received psychiatric services before? *

• Yes
• No

If yes, how long ago, with whom, for what, and results:

Many parents have opinions on psychiatric medications, what are yours? *

Does your child have any allergies (food, environmental, medicinal, animal, etc.) *

Any current or past medical issues, hospitalizations, accidents, injuries or surgeries? If yes, for what? *

Is your child presently under a physician’s care? If so, for what? *

List medications (over the counter & prescribed), nutritional or herbal supplements, alternative treatments (acupuncture, chiropractic, etc.) your child is taking/doing and reasons: *

Tell us about the pregnancy of your child (full term, preemie, any complications during pregnancy or at birth, environment and situations during pregnancy and birth). *

Tell us about your child’s development milestones (delayed, on time, early) *

Important Questions We Must Ask

Has your child ever had suicidal ideations? *

• Yes
• No

If yes, please explain:

Has your child ever planned to hurt himself/herself? *

• Yes
• No

If yes, please explain:

Has your child ever attempted to hurt himself/herself? *

• Yes
• No

If yes, please explain:

Has your child ever felt like he/she wanted to seriously hurt or harm someone else? *

• Yes
• No

If yes, please explain:

Do you have weapons in your home or access to weapons? *

• Yes
• No

If yes, who has access to them and what are the safety protocols around them?

Is there any history past or present of abuse or violence? *

• Yes
• No

If yes, please explain:

Is your child currently using any illegal drugs or is the reason you are seeking therapy services substance related? *

Has your child ever witnessed or experienced a trauma? Does your child have reoccurring nightmares, flashbacks, or avoids anything that is uncomfortable or painful? If so, please explain: *

Are you concerned your child may see or hear things that don’t appear to be real? If so, please explain: *

Has your child even been arrested, been involved with the juvenile justice system, or is engaging in behaviors that put him/her at risk? If so, please explain? *

Do you have any concerns about your child’s sexuality, gender or sexual development? *

Education, Responsibility, Recreation and Leisure

What school does your child attend? *

What grade is your child in? *

How are your child’s grades? *

Has your child ever been held back or receive specialized academic services? If so, for what? *

What concerns if any do you have about your child’s education or schooling (grades, peers, relationships with teachers, etc)? *

What would your child say he/she likes and dislikes about school: Likes *

What would your child say he/she likes and dislikes about school: Dislikes *

What responsibilities does your child have at home? *

If your child is age 15 yr. and above what other skills do you think your child needs to be independent? How is he/she learning them? What else does he/she need to gain independence? *

What other responsibilities or skills would you like to see your child have/achieve? *

Does your child have his/her own cell phone? *

• Yes
• No

What are the rules around your child’s cell phone use? Who enforces those rules? *

Understanding Your Family

If 1 or both parents are absent, if so for how long and reason for absences: *

If parents are not together please describe the parents’ relationship with one another: *

Who lives in the house with the child? *

If parents are not together who lives in the other house with the child? *

Does your family have any pets? If yes, names, types and relationship to each pet: *

List 5 or more strengths of your family: *

Is there anything that gets in the way of your family being the way you want it to be? *

Describe your child’s relationship with the following: Father and Mother *

Describe your child’s relationship with the following: Siblings: Age, Name and Sex: *

Describe your child’s relationship with the following: Significant Other: *

Describe your child’s relationship with the following: Other(s): *

Does your family belong to any religious or spiritual groups? *

• Yes
• No

If yes, what is your level of involvement?

Who else do you consider to be part of or supportive to your family (people or affiliations): *

Is there any thing else that you think is important for us to know about your child? *

Terms of Use *

• Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold TJocelyne Counseling and Consulting Clinic LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

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425 Pleasant Street

First Floor suite 102

Brockton, MA 02301

Call:  (508) 580-0364

Email: intake@tjocelyne.org

Send Your Question...

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Name *

First

Last

Phone *

Email *

Comment or Message *

Terms of Use *

• Yes, I want to submit this form By submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold TJocelyne Counseling and Consulting Clinic LLC harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Submit