Client Information: Ages 5-11Today’s Date: ______
Are you the parent or guardian of the minor client? Y N
Name and Relationship: ______
Home street address: ______Apt: ______
City: ______State: ______Zip: ______
Cell phone: ______Home phone: ______
Email: ______
Calls will be discreet, but please indicate any restrictions:
Client’s name: ______DOB: ______Age: ______
Insurance/Payment Information
Will you be using insurance to pay for sessions? Y N
Member’s name: ______
Member’s date of birth: ______
Insurance company: ______
Member ID: ______Group #: ______
Dependents: ______
How did you hear about us?
⏮ Website ⏮ Google ⏮ Psychology Today ⏮ Referral ⏮ Other: ______
Your medical care:
From whom or where does the client receive medical care? ______
Clinic/doctor’s name: ______Phone: ______
Client’s School Information
School: ______
Phone: ______Grade: ______
Emergency Contact
Name: ______
Phone: ______Relationship: ______
Do I have permission to contact this person in the event the client or guardian is unable to consent to medical treatment? Y N
Please check any current or past issues that apply to the client:
___ Abuse (physical, sexual, emotional)
___ Sibling issues
___ Family distress
___ Divorce/custody/visitation issues
___ Nervousness around others
___ Stress/anxiety
___ Phobias (type: ______)
___ Feeling uptight/tense
___ Worrying
___ Nightmares
___ Feeling afraid
___ Difficulty concentrating
___ Difficulty sleeping
___ Lying to others
___ Homicidal thoughts or comments
___ Explosive behavior
___ Violence or aggression
___ Anger
___ Alcohol/other drug use
___ Skin or hair picking
___ Harm to animals
___ Restrictive eating
___ Physical symptoms (i.e. headaches, stomach aches)
___ Self-harm
___ Fire starting
___ Stealing
___ Eating binges
___ Sexual preoccupation or obsessions
___ Memory loss or blackout
___ School/Work issues
___ Sexual/gender identity issues
___ Social concerns
___ Grief and loss
___ Crying
___ Feeling helpless
___ Feeling out of control
___ Loneliness
___ Depression
___ Feeling hopeless
___ Feelings of guilt
___ Withdrawing socially
___ Feelings of self-doubt
___ Suicidal thoughts or comments
Please feel free to elaborate on any issues:
Please list any medications and dosages the client is currently taking:
Please list any hospitalizations (psychological or medical):
Please describe any family history of mental illness:
Please provide the names and nature of the relationships of all individuals residing in the home with the client:
Please summarize the reason the client came to see me today:
Guardian Rights
Your Name (please print):______
Your relationship to the child: ▢ Parent ▢ Step-parent ▢ Guardian ▢ Grand-parent ▢ Other
I am 18 years of age or older. ▢ Yes ▢ No
Marital/relationship status: ______
If parents/caregivers are divorced, it is essential that the legal custodian of the minor grant permission for the services provided. You may be asked to provide a copy of the court order that names you the legal custodian of the above minor. Are you willing to do so? ▢ Yes ▢ No
I have the following legal custody (check appropriate): ▢ Joint ▢ Sole ▢ None
I have a legal right to obtain treatment and make medical decisions for the minor: ▢ Yes ▢ No
Is there another party that needs to consent to treatment for the client? ▢ Yes ▢ No
If yes, contact information: ______