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Age: *
Birthplace: *
Name of parent(s)/guardian(s) who have legal custody of child (All legal parent(s)/guardian(s) MUST provide written consent for services): *
Phone Number(s): *
How were you introduced to us? *
If you found us online what words did you search to find us? *
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. *
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: *
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) *
If yes, please explain:
If yes, please explain:
If yes, please explain:
If yes, please explain:
If yes, who has access to them and what are the safety protocols around them?
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? *
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? *
What are the rules around your child’s cell phone use? Who enforces those rules? *
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): *
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? *
