Personal Data Inventory for Teenagers 13-17 (to be filled out by the teen)
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Date of Birth
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Siblings Names and Ages:
Street Address Line 2
State / Province
Postal / Zip Code
Primary Family Phone #
Your Cell #
Are you able to send and receive texts?
Your email address:
Are your parents currently married and living together? If not, what is your situation? Explain:
Who is your medical doctor?
When was the last time you had a checkup?
Are you in good health? If not, explain:
What medications are you taking, and what are they for?
Have you received any other counseling? Where?
Are you currently seeing another counselor? Who?
What grade are you in, and at what school?
How are you doing in school in general?
Do you have learning challenges? Explain:
What church do you attend? How often do you attend?
What church activities are you involved in? (Sunday School, Youth Group, Volunteering, etc.)
Please describe what brings you for counseling at this time:
What are your goals and hopes for this counseling?
What kinds of things have you tried to help your current struggles?
Please briefly describe yourself (Shy, outgoing, sensitive, kind, a bully, anxious, unhappy, obedient, etc...use whatever words fit your description):
What are some of your interests?
Have you ever used street drugs, marijuana, alcohol, or other substances? What, when and for how long?
Have you ever done anything illegal, and do you have a police record? Explain:
Have you ever been sexually active? Are you currently?
Is there anything else you think your counselor should know? Explain:
Should be Empty:
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