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? YesNo Employment Education Email Agree to receive invoices by encrypted email? YesNo Co-Parent’s Name Phone Address Agree to be involved? YesNo Employment Education Email Agree to receive invoices by encrypted email? YesNo Any significant others involved in child care? YesNo Siblings Name: Age: Grade/School: At Home?: YesNo Name: Age: Grade/School: At Home?: YesNo Educational Last Grade Completed/Current Grade: 1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th 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?YesNo 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? YesNo Is there anything else you would like the therapist to know, or would like to ask the therapist about?
