Teen/Young Adult Questionnaire

Lauren Hutchinson

Teen/Young Adult Questionnaire
Tell me a little about you...

(If you are age 13 and up, anything you say here will be help in complete privacy, including from your parents.)
Your Name First Name   Last Name Date of Birth   Date

Current School and Location  Grade/year in college

Home Address Street Address   Address Line 2   City

Mobile Phone Phone Number E-mail Email

If working right now, what's your job?
What's your gender identity?

Female Male Gender non-binary Other
What do you do for fun when you don't have to be serious?
Things you do in your free time, i.e. hobbies, extra-curriculars, passion areas, interests, etc.
What are you good at? (Yeah, I'm asking you to brag about yourself)
This can be anything including music, art, outdoor activities, organized sports, gaming (video, RPG, board), math, science, writing, reading, coding, theater, debate, entrepreneurship, crafting, cooking, helping others, mechanics, gardening, taking care of animals, engineering, inventing, world-building, non-profit or social justice work, helping others, etc. It can also be any qualities you have like being funny, a good friend, a positive attitude, loyal, conscientious, creative, etc.
Describe a really good day. What would you be doing? Who would you be with?
Think of people, places, and things that make you happy.

What stresses you out? What are the things that bring you down or crush a good vibe?
Think of people, places, activities, and situations that cause you stress or unhappiness.
What do you wish could be better in your life? What problem/s would you like to solve?
This can be anything! Some things people have said include getting to know themselves better, do better in school, have better friendships and relationships, be less irritated/frustrated all the time, not be so worried a lot, be less perfectionisty, be less sad, deal with toxic people, figure out high school or college, game less and stretch a comfort zone by doing other things, be less socially anxious or awkward around people, stop having panic attacks, be healthier, feel good about who you are, figure out sexual or gender identity stuff, etc.
I don't believe that diagnoses are our identities or put us in any box (unless we want them to), but they are information. Do you have any diagnoses you want to share? How relevant do you think they are to what you're going through now?
Examples might include ADHD, autism, anxiety, depression, dyslexia, dysgraphia, dyspraxia, dyscalculia, PANDAS, epilepsy, food allergies/sensitivities or other medical conditions.
Have you seen a counselor before? If so, how long ago and how did it go? You can share the name if you want.

How many hours of sleep do you get on a typical night?
How many hours are you looking at a screen on a typical day (unrelated to school)? (You can be honest, you won't get a lecture from me)
What are your favorite games, apps, or social media platforms?
If the work we do together has a positive outcome, what would change or be different? What specific struggles would be relieved? Is there anything else you want me to know about you?
Thanks for taking the time to fill this out. We are all complex humans who are unique. I really want to know what makes you the person you are. I look forward to seeing you soon.

Lauren
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Lauren Hutchinson