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
Work Phone
Cell Phone
Email*
Calls will be discreet, but please indicate any restrictions
YesNo
Referred By:
YesNoN/A
YesNoN/A
Person to notify in case of any emergency*
Emergency contact phone number*
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*

Clear
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

YesNo
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?*
MarriedDivorcedSeparatedWidowedOther
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
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Family History Of (Check all that apply)
Drug/Alcohol AbuseLegal TroubleDomestic ViolenceSuicidePhysical AbuseSexual AbuseHyperactivityLearning DisabilitiesDepressionAnxietyPsychiatric HospitalizationNervous Breakdown
Any Other Information You Would Like to Include?
Parent/Guardian Signature*

Clear
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)