Therapy Adolescent Supplemental Information

Adolescent Intake Supplemental Information
1701 48th St, Ste 120, West Des Moines, IA 50266, 515-331-0303
Name:

First NameLast Name
Date of birth:

MonthDayYear
Date
Why are you coming for an appointment?
Whose idea was it that you come?
Please check those that apply to you:
Check any Compulsive Behaviors you might have:

Other
Check any Panic symptoms you might have:
Check any of the options below that apply to you:
Are there any other concerns not listed above you want to discuss?
What are some things you are good at? (Strengths? Favorite things?)
What are some things you're not very good at? (Weaknesses? Least favorite things?)
Do you have at least one friend who you really like and feel you can talk to?
Do you think that your parents really listen to you and take your feelings seriously?
What do you like about your family?
What do you dislike about your family?
Have you had fun in the last two weeks?
If yes, what were you doing to have fun?
What words would you use to describe yourself?
If you could change one thing about your life or yourself, what would it be?
What do you like about school?
What do you dislike about school?
How do you feel about your teachers?
What extracurricular activities are you involved in ?
Do you have a phone?
If yes, what social media apps do you use?
Do you play video games?
If yes, what games do you play?
Anything else you would like us to know about you or your situation?
Should be Empty:

Adolescent Intake Supplemental Information