Snake River Counseling
Youth Client Information Packet
Client Name:______DOB:______
Precipitating Event(s)
Please describe the concerns that brought you in today.
Environmental Assessment
Who lives in your home (parents, siblings, roommates, etc.) and how do you get along with them? Please include any additional life stressors.
Psychiatric Problems
Depression – Has your child had a period of time during which they felt unhappy, depressed, and irritable and felt no interest in life consistently for at least two to four weeks?
High Periods or Mania – Have they had moods that lasted one week or more in which they had so much energy they did not sleep for several nights, or felt they could accomplish many difficult tasks easily? Were they feeling so good that others commented on their elevated mood?
Chronic Feelings of Unhappiness – Has your child felt mildly unhappy, or unable to enjoy life, for many years, for no apparent reason?
Chronic Tension and Anxiety – Has your child ever had problems with chronic anxiety, tension, nervousness, or constant worrying? Do they worry about minor concerns? (Not connected to anxiety attacks)?
Panic Attacks – Has your child ever had brief anxiety attacks during which they felt like you were going to die, lose control, were very frightened, extremely anxious, or uncomfortable?
Panic Associated Fears – Has your child ever been afraid of going out of the house alone, going to the grocery store, driving, or using public transportation because of fear of having a panic attack?
Obsessive/Compulsive Symptoms – Has your child ever had compulsions to repeat tasks such as checking things, washing hands, counting, or obsessions (ideas that make no sense by keep repeating in their mind)?
Social Fears or Phobias – Has your child been fearful in specific social situation, or felt uncomfortable doing things in front of other people? Do they worry excessively about being embarrassed, or humiliated in social situation?
Phobias – Does your child have significant phobias such as heights, flying, closed spaces, insects, etc. that interfere with their life?
Posttraumatic Symptoms – Has your child ever experienced any traumatic events that have continued to bother them, or caused emotional problems such as nightmares or flashbacks of the event?
Hyperactivity/Inattentions – Has your child been considered hyperactive and/or inattentive, been treated with Ritalin or another stimulant, or been diagnosed with ADHD?
Psychotic Symptoms – Has your child ever had hallucinations, heard voices, felt they had special powers, were receiving special messages, or felt inappropriately suspicious that people were trying to hurt them?
Chronic Physical Symptoms – Has your child ever had a period of time during which they felt physically sick or worried about their health when no physical cause could be found?
Chronic Pain – Has your child had problems with chronic pain such as stomachaches or headaches?
Sleep Problems – Has your child experienced sleep problems such as insomnia, oversleeping, frequent nightmares, or sleepwalking?
Anorexia – Has your child ever been anorexic or purposely lost weight to obtain a weight below normal?
Binge Eating or Bulimia – Has your child had eating binges associated with inducing vomiting using laxatives, or exercising to the extreme?
Temper/Anger Problems – Does your child have problems with their temper?
Dissociative Symptoms – Has your child had periods of time during which they feel “out of touch,” removed from the world around them, or lost large amounts of time that they cannot account for?
Self-harm – Besides attempting suicide have they ever attempted to physically harm themselves in other ways such as cutting or burning?
Risk Assessment
Suicide: (please describe any current or past thoughts, feelings, intentions, plans, or attemptsyour child has had to end their life)
Homicide: (please describe any current or past thoughts, feelings, intentions, plans, or attempts your child has had to end someone else’s life)
Do you feel immediate intervention is required to keep your child or others safe?
Previous Psychiatric Diagnosis and Treatment
Are they currently receiving services from a mental health provider? (Therapy, PSR, Service Coordination, Medication. etc.) If so, which providers?
Have they had mental health services in the past? (Therapy, PSR, Service Coordination, Medication. etc.) If so, which providers?
Have they ever been admitted to residential treatment program or psychiatric hospital? If so, which program or hospital for how long?
Please share any psychiatric problems in your biological relatives, consider problems such as depression, bipolar disorder, anxiety disorders (OCD, panic disorder, PTSD), schizophrenia, ADHD, anger or criminal problems, suicides, etc.
Potentially Problematic Behaviors
Do they drink alcohol, if so how much and how often?
Do they or those who they associate with believe they have a drinking problem?
Drug Abuse – Have they ever abused “street” or prescription drugs?
Which ones and what age were they?
Have they ever participated in a substance abuse program?
Inpatient:
Outpatient:
Is there a family history of substance abuse?
Do they smoke cigarettes or use tobacco products?
Do they regularly consume caffeinated beverages? (Soda, tea, coffee, energy drinks, etc.)
Do they have any other behaviors that someone in their life identifies as impeding their daily functioning and interaction (gambling, spending, work, sex, pornography, video gaming, etc.):
Medical History and Functioning
Who is your primary care physician and when was the date of your last physical?
How is the child’s overall health?
Do they have any major health concerns? (High blood pressure, headaches, seizures, heart problems, etc.)
Are they on any medications?
Do they have any major allergies?
Have they had any major accidents, illnesses, or injuries?
Did the child or the mother experience any difficulties during labor, delivery, or the newborn period?
Was there any use of substances by the mother during the pregnancy?
Did the child spend a significant amount of time separated from the primary care giver(s) for any reason?
What was the reason?
Has anyone expressed concerns over the child’s development?
What kind of concerns?
Any Family History of major medical concerns? If yes, please explain
Family History and Functioning
Where was the child born?
What was the relationship status of the parents at that time?
Was the child adopted?
At what age were they adopted?
Adoptive Parents:
Biological Parents:
Step-Parents (if applicable):
What is the custody arrangement for the child?
Any children living outside of the home?
Are there any siblings that are deceased?
Has the child ever been placed outside of the home?
What is the family’s cultural and/or religious background?
Has the child been physically or sexually abused or molested?
Has the child witnessed domestic violence?
What is the structure and discipline like within the home environment?
Where did the child live growing up?
What resources and supports does the child/family have?
What are the child’s strengths in the family setting?
Social History and Functioning
How would you describe the child’s friendships? (No friends, acquaintances, acquaintances and friends)
How would you describe the child’s behavior and comfort level in social situations?
What kind of extracurricular activities does your child participate in?
What are their social talents or strengths?
Adolescent only:
What is their sexual orientation?
Are they currently in a romantic relationship? If yes, please describe that relationship?
Are they sexually active?
Vocational/Educational History and Functioning
What school does the child attend?
What grade?
Have they ever had specialized learning plans (IEP, 504, etc.) or extra tutoring?
Does the child have behavioral problems in school (suspended, expelled)?
How does the child do in school academically?
How does the child do in school socially?
What are the child’s strengths and talents in the school setting?
Has the child ever been employed?
Have they ever been reprimanded, fired, or participated in a work program?
What are their skills or interests?
Financial History and Functioning
Please describe the family’s source of income.
Do you or your children receive support from state or federal programs?
Do you have a history of financial problems?
Basic Living Skills History and Functioning
Can the child maintain basic hygiene routines? (Bathing, brushing teeth, dressing in clean clothes)
Do they need repeated prompting to do so?
Are they able to perform safety practices?
Calling 911?
Refraining from playing with fire?
Using adequate caution when crossing the street?
Using adequate caution when engaging strangers?
Locking doors and using a key?
Can the child
Prepare meals?
Shop for items?
Develop regular schedules and routines?
Will the child be 18 soon and living on their own?
Housing History and Functioning
What are your current living arrangements? (Rent, own, live with family, etc.)
Is this living arrangement what you would consider healthy and safe?
Is there any history or current risk of homelessness?
Community/Legal History and Functioning
Does the child have any current or past involvement with the legal/court system?
Motivation/Readiness for Treatment:
Explain your child’s motivation and readiness for treatment:
What are your/your child’s strengths and barriers towards treatment?
What are some goals you would like your child to accomplish in treatment?
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