Parent Child Therapeutic Services
Caregiver Information:
Parent/Guardian Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
/
Month
/
Day
Year
Date
Age:
Geographical Location & Housing Type:
N Portland
NW Portland
SE Portland
SW Portland
DV Shelter
Houseless
Doubled Up Temporary
Doubled Up Permanent
Rent House/Apartment
Own House/Condo
Other Shelter
Transitional Housing
Other:
NE Portland
Marital Status
Single
Married/Partnered
Separated
Divorced
Parent/Guardian Ethnicity:
Latino/Latina
White
Slavic
African-American
Pacific Islander
African Immigrant
American Indian
Asian Immigrant
Asian
Primary Language Spoken in the home
English
Other
Custody Type:
Biological Mother
Biological Father
Grandparent
Other
Parent/Guardian Gender
Female
Male
Non binary
Not given
Source(s) of Household Income
Child Support
Employment
Unemployed
TANF
SSI
Food stamps
Other
Average Monthly Household Income:
Other Economic Information?
Parent/Guardian Military Status
Never served
Currently Enlisted
Discharged
Retired
Decline to answer
Parent-Child Counselor Name (If Known):
Referred by: (Include Name & Contact Information If known)
Who referred you to our services?
Date of Referral:
/
Month
/
Day
Year
Date
Involved with CPS?:
Yes
No
In the Assessment Phase?
Voluntary CPS Case?
Transportation Available?
No
Yes
Other
Today's Date:
/
Month
/
Day
Year
Date
Primary Client Information
Person to Receive Services
*Primary Client Name (and/or Child to Receive Services)
First Name
Last Name
Gender
Male
Female
Other
Refuse to answer
Age
Race/Ethnicity
Latino
Black/African
Native American
Asian/Pacific Islander
White
Eastern European
Other
Date of Birth
-
Month
-
Day
Year
Date
Siblings or other Family Members
Rows
First & Last Name
Age
Gender
Ethnicity/Race
Ethnicity/Race
Date of Birth
Lives with Caregiver?
Sibling or Family Member
Male
Female
Non-binary
Not given
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Sibling or Family Member
Male
Female
Non-binary
Not given
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Sibling or Family Member
Male
Female
Non-binary
Not given
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Sibling or Family Member
Male
Female
Non-binary
Not given
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Latino
Black/African American
Asian/Pacific Island
Native American
Eastern European
White
Other
Describe the Main Reason you are seeking services now:
How will you know services were successful after they have ended?
What would you like to accomplish?
Please check all that apply (for the Primary Client):
Anger or hostile feelings
Anxiety, nervousness, fears
Sadness or Depression
Family issues
Procrastination
Emotional distress
Family & Relationships concerns
Shyness
Traumatic experiences
Social conflicts
Suicidal feelings or behaviors
Stress
Sleep disorder
Self-control
Self-esteem or confidence
Work or career concerns
Parenting issues
Grief
Other
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Family History
Include Strengths, Challenges, Siblings or Other significant information to consider
Cultural Considerations you would like to included
Include Language, Spiritual, or Other Considerations
Accommodations Needed?
Sight, Hearing, Physical, or Other Needs
School/Preschool
Include IEP, Discipline, or Other Important Information
List any *Past or *Current Counseling or Mental Health Services Received
School Counseling, Psychologist, or Others
Strengths (Include Clients Interests, Hobbies, or Other Information)
Strengths
Were there any Health Challenges Before or During Birth?
Any past hospitalizations or health concerns?
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