Client Admission

    Client Info:

    Family Structure:

    Agree to be involved?
    Agree to receive invoices by encrypted email?
    Agree to be involved?
    Agree to receive invoices by encrypted email?
    Any significant others involved in child care?

    Siblings

    At Home?:
    At Home?:

    Educational

    Last Grade Completed/Current Grade:
    Concerns at school: talks outtrouble focusingdistractiblepoor attention spanpoor academic performancepoor social skillsaggressivedestructiveanxiousoveractiveoppositional
    Does the child have a current Psychiatrist or Primary Therapist treating this concern?

    Any Prior Therapy?

    Medication History

    Treatment Information and Goals:

    Are you able to commit to regular attendance?

    410-353-5708