Carolyn Aibel, Ph.D., Licensed Clinical Psychologist
INFORMATION SHEET FOR CHILDREN/ ADOLESCENTS
To be filled out by Parent(s)/ Guardian(s)
Date of birth:
Parent/ Guardian Name(s):
Where do you prefer I call?
May I leave a message identifying myself?:
Referred by (if applicable)
Please describe your current concerns about your child and the history of these concerns:
Please describe what you would hope your child will gain from therapy:
What would have to change in your child's life so that you would know he/she was done with this phase of therapy:
Describe the current composition of your child's family:
Please list any significant losses/ traumas your child has experienced:
Please list any previous psychotherapy treatment (therapist names and approximate dates):
Is your child currently on any medications? Or has she/ he been on any in the past? (If yes, please indicate what medication is/ was treating.)
Is there anything else that would help me to know for therapy to be more useful and helpful to your child?
Should be Empty:
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