Have they received any psychological testing? Yes No When? blank .
Anxiety - How long blank Depressed mood - How long Low energy level - How long Racing thoughts - How long Poor concentration - How long Indecisiveness - How long Change in sleeping - How long Change in appetite - How long Angry outbursts - How long Crying spells - How long Lack of motivation How long Weight change How long Feeling others are against him/her How long Excessive guilt How long Isolation How long Mood swings How long Feelings of hopelessness How long Low self-esteem How long Difficulty with memory How long Thoughts/plans of suicide How long Self-harm How long Thoughts/plans to hurt others How long Alcohol use How long Drug use How long Bedwetting How long Soiled pants How long Trouble in school How long Truancy How long Trouble with peers How long Disobedient How long Conflict with family How long Running away How long Problems with the law How long Rocking How long Head-banging How long Destructive How long Fire-setting How long Harm to animals How long Infantile How long Sexual behavior How long Lying How long Over-active How long Fearful How long Impulsive How long Phobic How long Other Issue How long Other Issue How long
Where has your child lived? blanks Age when living there to blank Age when living there to Age when living there to Age when living there to
Physical (exercise/nutrition): blanks Emotional: blank Spiritual: Mental health: Family: Friendships: School:
Has your child been retained at school? Type option 1 Type option 2 What grade? blanks
I hereby authorize Ginger Gray, LCSW and Abiding Hope Christian Counseling, to disclose the individually identifiable health information as described below, which may include psychotherapy notes. I understand that if I do not sign this form, federal and state law will prohibit Ms. Gray and her practice from releasing records regarding her treatment of me/my child to the designated Recipient. By accepting the records pursuant to this Authorization, the Recipient acknowledges that the protected health information covered by this release is confidential, privileged and protected by federal and state privacy statutes and regulations, and agrees that Ms. Gray’s release of the individually identifiable health information will continue to be protected by federal and state privacy statutes and regulations
I intend for this Authorization to remain in full force and effect until I revoke it in writing. Further, it is my intent that a copy of this Authorization shall have the same effect as the original. I further understand that I may revoke this authorization at any time by notifying Ginger Gray, LCSW in writing at Abiding Hope Christian Counseling, 19115 FM 2252, Suite 12, San Antonio, TX 78266. I also understand that the written revocation must be signed and dated with a date that is later than the date on this authorization. The revocation will not affect any actions taken before the receipt of the written revocation.