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Child Client
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Birthdate: | |
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Gender: | |
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What are the concerns about your child for which you are seeking assistance? |
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Family Information
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Race: | |
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Cultural Considerations: | |
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Family History of Mental Health or Substance Abuse Problems: | |
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Explain: |
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Child's Parents |
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Parents |
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Annual Family Income: | |
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Language Spoken: | |
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Family Size: | |
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Client's Brothers and Sisters |
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Other Household Members |
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Who does your child live with currently? | |
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Who did your child live with previously? | |
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Describe your child's relationship with: |
| Description | | Parents: | | Siblings: | | Extended Family Members: | | Teacher(s): | | Other Children: | | |
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List any family members you wish to have involved in treatment and why: |
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Physical Description
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Height: | |
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Weight: | |
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Recent Gains or Losses | |
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Other distinguishing features: | |
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Does your child have any physical impairments or disabilities? If so, explain: |
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Are physical characteristics or body image a concern? Explain: |
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Education
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Name of Current School: | |
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Current grade: | |
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Name of Teacher: | |
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Name of School Social Worker: | |
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Special Education? | |
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If yes, type of Spec Ed certification: | |
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Did not complete school? | |
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Last school attended: | |
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Grade Completed: | |
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Is or was your child’s school performance a concern? | |
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Explain: |
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Can your child read well? | |
Employment
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Is your child currently employed? | |
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If yes: | |
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Name of employer? | |
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Comments: |
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Spiritual Information
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Is spirituality an area of support or strength for your child? | |
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Religion: |
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Is this an area of concern? | |
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Explain: |
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Sexual Functioning / Sexuality / Gender Identity
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Is this an area of concern? | |
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Explain: |
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Community Services Received Currently or Previously
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Previous Mental Health Counseling / Substance Abuse Treatment: |
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Was previous counseling/treatment helpful to your child in the past? | |
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Previously or Presently Attended Support Groups |
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Was support group attendance helpful? | |
Substance Use
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Does your child use illegal or unprescribed drugs including alcohol? | |
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If yes, explain which drugs, amount and frequency: |
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Does your child misuse prescription drugs? | |
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If yes, explain which drugs and how they are misused: |
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Has anyone ever expressed concern with your child's use of alcohol or other drugs? | |
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If yes, explain: |
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Does your child smoke cigarettes now or in the past? | |
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If yes, explain time period, amount and frequency: |
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Social Life
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Describe your family's strengths: |
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Describe your child's support system: (ie. family, friends) |
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Describe your child's recreational interests: |
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Describe any relationship problems with friends/peers: |
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Health History
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Primary Physician: |
Name: | | Address: | | Address Line 2: | | City: | | State: | | Zip Code: | | Phone: | | | (Business) | | (Cell) | Email: | | |
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Date of last physical exam: | |
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Pharmacy (include Street, City): | |
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Phone: | |
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Medications: List all current prescriptions, regularly taken over the counter meds and supplements |
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Are there concerns about medications including drug allergies? | |
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Explain: |
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Health Problems |
| Status | Family History | | Allergies | | | Anorexia | | | Asthma | | | Broken Bones | | | Communicable Diseases | | | Diabetes | | | Fainting/Dizzy | | | Hearing Problems | | | Heart Disease | | | High/Low Blood Pressure | | | High/Low Blood Sugar | | | Liver Disease, Jaundice | | | Major Injuries | | | OB/Gyn Problems | | | Obesity | | | Seizures/Epilepsy | | | Stomach or Intestinal Problems | | | Thyroid Problems | | | Ulcer | | | Vision Problems | | | |
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Assistive Technology Needed? | |
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Comments: |
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Developmental Issues List any developmental skills that your child accomplished ahead of or behind others the same age, (examples: walking, talking, reading, etc.) |
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Does your child have generally good nutrition habits? | |
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Special diet required: | |
Abuse History
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Has your child experienced physical, sexual or emotional abuse? | |
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Explain: |
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Legal History
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Does your child have any history of legal charges? | |
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Explain: |
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Is your child currently on probation? | |
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Probation officer's name: | |
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Is treatment court ordered? | |
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Are there custody / visitation concerns? | |
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Explain: |
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Other Relevant Concerns
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Please describe any other relevant concerns: |
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Notes |
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Form Updates |
Name |
Date |
Action |
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Form Started
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