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Client Admission

Date

Referred By

Client Info:

Client’s Name

Date of Birth

Address

School/grade/work

Family Structure:

Parent’s Name

Phone

Address

Agree to be involved?

Employment

Education

Agree to receive invoices by encrypted email?

Co-Parent’s Name

Phone

Address

Agree to be involved?

Employment

Education

Agree to receive invoices by encrypted email?

Any significant others involved in child care?

Siblings

Name:

Age:

Grade/School:

At Home?:

Name:

Age:

Grade/School:

At Home?:

Educational

Last Grade Completed/Current Grade:

School:

Concerns at school: talks outtrouble focusingdistractiblepoor attention spanpoor academic performancepoor social skillsaggressivedestructiveanxiousoveractiveoppositional

Other Concerns

Current Concerns that led to referral

Does the child have a current Psychiatrist or Primary Therapist treating this concern?

Name

Phone

Current diagnosis established for purposes of this treatment?

Any Prior Therapy?

Outpatient?

Inpatient?

Any Substance Use Concern? (If so, please describe type of substance, frequency, amount:)

Any safety concerns?

Medication History

Current medications, dosage and dates, (include any supplements, OTC meds taken regularly)

Discontinued medications? (If any, please list meds and dates started and stopped:)

Any substance use concerns? If so, please describe type of substance, frequency, amount

Treatment Information and Goals:

List down Current symptoms, concerns or problem behaviors to address in therapy

Trigger(s) for onset of current symptoms, concerns, or problem areas:

Additional information about these current symptoms, concerns or problem areas:

Goals or expectations of therapy? Please, be as specific as possible

Concerns about therapy or the therapeutic process?

Are you able to commit to regular attendance?

Is there anything else you would like the therapist to know, or would like to ask the therapist about?

We will be glad to answer your questions, feel free to ask a piece of information or a quotation. We are looking forward to work with you.

410-353-5708

brobertson.atr@gmail.com

Annapolis, Maryland

Home
Articles
Why Art Therapy?
About Me
Services
Contact Us
Privacy Policy

410-353-5708