Client Information Form for Minors

Client Information Form for Minors

This form is completely confidential
Today's Date

MonthDayYear
Your Child's Name

Child's First NameChild's Middle NameChild's Last Name
Child's Date of Birth

MonthDayYear
Gender
Parent or Legal Guardian's Name

First NameMiddle NameLast Name
Parent or Legal Guardian's Social Security Number
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent or Legal Guardian's Name of Employer
Parent or Legal Guardian's Employer Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Cell Phone
Format: (000) 000-0000.
Email
Calls will be discreet, but please indicate any restrictions
Telehealth option: If my primary therapy is face-to-face, but an emergency arises on my part or on the part of the therapist or environmental emergency that inhibits one or both of us from being in the office, I am willing to use telehealth as an alternative for that particular session.Type a question
Referred By:
May I have your permission to thank this person for the referral
If referred by another clinician, would you like for us to communicate with one another?
Person to notify in case of any emergency
Emergency contact phone number
Format: (000) 000-0000.
We will only contact this person if we believe it is a life or death emergency. Please provide your name to indicate that we may do so
Please briefly describe your child's presenting concern(s):
The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.
What are your/your child's goals for therapy?
The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.
How long do you expect to be in therapy in order to accomplish these goals (or at least feel like you have the tools to accomplish them on your own)?
The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.
Medical History
Please explain any significant medical problems, symptoms, or illnesses your child has had

Current Medications

Rows	Name of Medication	Dosage	Purpose	Name of Prescribing Doctor
Medication One
Medication Two
Medication Three
Medication Four

Previous Medical Hospitalizations

Rows	Approx Start Date	Approx End Date	Reason
Hopitalization One
Hospitalization Two
Hospitalization Three

Previous Psychiatric Hospitalizations

Rows	Approx Start Date	Approx End Date	Reason
Psychiatric One
Psychiatric Two
Psychiatric Three

Has your child ever talked with a psychiatrist or psychologist?
Family
How would you describe your child's relationship with his or her mother?
How would you describe your child's relationship with his or her father?
Parent's relationship status?

Other
How old was the child at the time of separation or divorce?
How would you describe your child's relationship with his or her grandparents?
Were there any other primary care givers who have had a significant relationship with your child? If so, please describe how these people may have impacted your child’s life:

Number of Siblings

Rows	Number	Ages
Brothers
Sisters

How would you describe your child's relationship with his or her siblings?
Social Support, Self-Care, and Education
Child's current level of satisfaction with friends and social support

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
How would you describe your child's relationship with his or her peers?
Please briefly describe any history of abuse, neglect, and/or trauma
Please briefly describe your child's self-care and coping skills
What are your child's diet, weight, and exercise/activity patterns
Please briefly describe your child's school performance and experience
What are your child's hobbies, talents, and strengths?
Please check all that apply to your child
Depression
Mood Changes
Anger or Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive Worry
Wetting the Bed
Trusting Others
Communication with Others
Seperation Anxiety
Alcohol/Drugs
Drinks Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Loss
Severe Weight Gain
Head Injury
Parents Divorced
Seizures
Cries Easily
Problems with Friends
Problems in School
Fear of Strangers
Fighting with Siblings
Issues Re-Divorce
Sexually Acting Out
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Thoughts of Hurting Someone Else
Hurting Self
Thoughts of Suicide
Sleeping Too Much
Sleeping Too Little
Waking Too Early
Nightmares
Sleeping Alone
Stomach Aches
Fainting
Dizziness
Diarrhea
Shortness of Breath
Chest Pain
Lump in Throat
Sweating
Heart Problems
Muscle Tension
Bruises Easily
Allergies
Often Makes Careless Mistakes
Fidgets Frequently
Impulsive
Waiting His/Her Turn
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Chills or Hot Flashes
Family History Of (Check all that apply)
Impulsive
Any Other Information You Would Like to Include?
Parent/Guardian Signature
Should be Empty:

Client Information Form for Minors

Medical History

Family

Social Support, Self-Care, and Education

Please check all that apply to your child

Family History Of (Check all that apply)