Sherpa Group Enrollment Application

Section 3: Referral Information
How did you first hear about Sherpa Group?
Please give the name(s) of the referral source, including phone and email:
Reason for referral: Chief complaint and symptoms (please be very specific including issues and home/school as well as any symptoms noticed such as mood changes, etc.)

Section 4: Family Information
Parents' current marital status

MarriedDivorced/SeparatedWidowedSingle
If divorced or separated, please provide the date:
How do you believe the divorce/separation has affected the Client? Please explain:
Is the Client adopted?

YesNo
What age was Client adopted?
Important circumstances surrounding the adoption process or afterwards:
Does the Client have any siblings?

YesNo
Please provide details about Client's Sibling(s)*
Were there any complications during birth mother's pregnancy or delivery? If yes, please explain.

Section 6: Placement Information
What specific events precipitated your decision to seek treatment?
What are your specific goals while receiving treatment?
What would you describe as the Client's strengths (intellectually, artistically, socially, physically, etc.)?
What would you describe as the Client's weaknesses (intellectually, artistically, socially, physically, etc.)?
Additional Comments:
Placement/Intervention History*
Has the client had any psychological testing?

YesNo
Please describe (include date/reason):
*Note: Please fax/e-mail/mail all previous testing from the last 3 years as part of this
application.

Section 9: Medications
Please provide any prescription and/or over the counter medications the client is currently taking. Please also include the reasons for each medication, dosage, and prescribing physician/phone:
Any known side effects of the medications? If yes, please describe:
Please describe previous history of medications (include name of medication, dosage, reason, prescribing physician):
Should be Empty:

Section 1: Client Information