Children Initial Questionnaire

Initial Questionnaire - Children
The following questionnaire includes questions related to your minor child. It should take approximately 15–20 minutes to complete. Please have your health insurance card, a photo ID for one parent, and information about your child’s doctor, medications (if any), and school information on hand. If you cannot complete it online, you may do so in the office, but you will need to arrive 30 minutes before your scheduled appointment. If you have any questions or concerns, please call us at 720-260-4115.

Please complete the information below. Your responses will be confidential. Provide as much information as possible. If you have any questions, you may ask them during the session. Be sure to include the child’s name and the parents’ names exactly as they appear on the child’s birth certificate. Remember that we need consent from both parents or the legal guardian with authority to make medical decisions for the child to authorize the start of counseling.
Child's Personal Information
Child's Full Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
MaleFemaleOtherOther
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parents' or Guardians' Contact Information
Married or Civil UnionLiving TogetherSeparatedDivorcedOther
Parent or Guardian Full Name*

First NameLast Name
Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
FatherMotherLegal GuardianOther
SíNo
Full Address Information*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent or Legal Guardian Name (2)
Parent or Legal Guardian Full Name (2)

First NameLast Name
SíNo
Full Address Information*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Authorization for Children's Therapy
For a minor client to receive mental health services, consent must be provided by the appropriate party. Review the situations below and indicate which one applies by selecting the appropriate option. If you are unsure which situation applies or whether you are able to consent to treatment for the minor client, please speak directly with the therapist before proceeding with your appointment.
I am a biological or adoptive parent currently married to the other biological or adoptive parent of the minor child. In this situation, either parent may give consent for mental health treatment.I am a biological or adoptive parent currently separated or divorced from the other biological or adoptive parent of the minor child. Please provide court paperwork that designates medical decision-making rights. If these rights are joint, both parents must consent for treatment.I am a biological parent who has never been married to my child’s other biological parent. Please provide court paperwork that designates medical decision-making rights. If these rights are joint, both parents must consent for treatment. If there is no legal order regarding medical decision-making rights, both parents must consent for treatment or, if applicable, the presenting parent must complete the “Parental Non-Involvement” section below.I am a biological or adoptive parent and the other parent is not involved in the minor client’s life or is not available to provide consent. In this situation, you must complete the “Parental Non-Involvement” section below.I am a legal custodian/guardian of the minor child. Please provide documentation verifying legal authority to consent to medical treatment.I am a Department of Human Services (DHS) Representative. For children in DHS custody, DHS is required to consent to treatment for those children in their care and to provide legal documentation demonstrating they hold medical decision-making authority.
If One Parent Is Not Participating, Please Explain. You indicated that one of the minor client's parents is currently unavailable to provide consent for treatment for the following reason:*
Child Behavior
Please indicate the main problem or concern that is bringing you to counseling (for example: anxiety, depression, behavioral challenges, bipolar disorder).*
MildModerateSevereExtremePrefer not to answer
Feels sad or depressedConstant anxiety or worryPanic attacksMood swingsAvoids other people or is very shyTrouble sleepingConstant fatigue or tirednessThreats of suicideSuicide attemptAlcohol useDrug usePoor school performanceHas been suspended from schoolHas difficulty pronouncing wordsSeems resentful or negativeDoes not seem to listen when spoken toForgets daily activitiesHas difficulty staying seatedRuns or climbs on things at inappropriate timesHas difficulty playing quietlyInterrupts othersLoses control easilyArgues with adultsDefies or does not follow instructionsBothers or irritates others on purposeBlames others for mistakesGets angry or irritated easilyMocks or bullies othersStarts fightsIs physically aggressiveHas stolenRuns away from homeMisses schoolDoes not pay attention to detailsDoes not finish tasks (school or home)Has difficulty organizingLoses things frequentlyIs easily distractedIs restless or cannot stay stillHas trouble waiting their turn
What are your goals in therapy? What goals would you like the child to achieve in therapy?
GOAL 1 What are your child's strengths? (For example: skills, positive qualities, interests, achievements, or ways they cope with challenges. Example: reducing anxiety or fears, improving self-esteem)*
GOAL 2 What are your child's strengths? (For example: skills, positive qualities, interests, achievements, or ways they cope with challenges. Example: reducing anxiety or fears, improving self-esteem)
GOAL 3 What are your child's strengths? (For example: skills, positive qualities, interests, achievements, or ways they cope with challenges. Example: reducing anxiety or fears, improving self-esteem)
YesNo
If yes, please explain.
Medical History
When was your last doctor's visit (aproximately)?*

DayMonthYear
Date
When was the last medical visit (aproximately)?*

DayMonthYear
Date
YesNo
If yes, please specify the illness(es):
Child School Information
School Name
Grade the child is currently in
School Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
School Phone
Please enter a valid phone number.Format: (000) 000-0000.
YesNo
If yes, please describe the difficulties:
YesNo
YesNo
YesNo
Additional Relevant Information About the Child
What are your child's strengths? (For example: skills, positive qualities, interests, achievements, or ways they cope with challenges)

Please provide information about the people who live in the home:

Rows	Full Name	Age	DOB	Relationship
1
2
3
4
5
6

Insurance
YesNo
Insurance Name
Policy Number
Take a picture of your Insurance Card - FRONT
Take a picture of your Insurance Card - BACK
Secondary Medical Insurance
It is very important that you inform us if you have additional insurance. Failure to provide information about your secondary insurance may cause billing problems. If this happens, you could be responsible for the full payment of sessions, as insurance companies may deny or withdraw payments if they do not receive correct information about your coverage. If your insurance denies charges because there is another plan that should be the primary insurance, you will be responsible for outstanding amounts, including possible external billing charges or bank fees. We ask that you inform us about any other medical insurance you have, now or in the future, to avoid inconveniences.
YesNo
Secondary Medical Insurance Type*
Secondary Policy Number*
Secondary Medical Insurance Photo - Front
Secondary Medical Insurance Photo - Back
Would you like to add any additional comments or information?
Should be Empty:

Initial Questionnaire - Children

Child's Personal Information

Parents' or Guardians' Contact Information

Parent or Legal Guardian Name (2)

Authorization for Children's Therapy

Child Behavior

Medical History

Child School Information

Additional Relevant Information About the Child

Insurance

Secondary Medical Insurance