Gigia Demko, MA, LMHC

2118 Caton Way SW

Olympia, WA 98502

PH: 360-402-7527 Fax: 360-352-3289

Teen Information

Date: ______

A. Identification Information

Name: ______DOB: ______SSN: ______

Address: ______Phone (Home): ______

City: ______State: ______Zip: ______Phone (cell) ______

School teen attends: ______Grade ______

School Telephone: ______

Custodial parent(s) or legal guardian(s) name and phone numbers: ______

______

B. Family Information

Number of siblings, their names and ages______

______

Are your parents□divorced□never married□still married

Teen is currently living with□biological mother□biological father

□step-mother □step-father

□foster mother □foster father

□other ______

Family History of:

□Depression□Suicide Attempts□Anxiety

□Eating Disorders□Mental Illness□Violence

□Sexual Abuse□Emotional Abuse□Alcoholism/Drug Addiction

□Chronic Illness (please explain) ______

□Other ______

______

C. Medical Information

Pediatrician/Family Physician: ______

Phone: ______Last Exam: ______

Major (or Chronic) Operations/Illnesses/Injuries ______

______

Current Medications Dosage(s) Frequency Effectiveness Prescribing Physician

______

Have you experienced any recent changes in:

□Sleep □Nightmares □Mood □Anxiety □Eating/Appetite□Weight□Energy level

How would you characterize your overall health?

□Poor□Fair□Good □Excellent

Do you smoke? □Yes □No Smoke in the past? □Yes □No

Packs/Day ___ How many years? ___

When did you quit? ______

Do you consume any alcohol? □Yes □No □Beer □Wine □Hard liquor

□Less than 1x/mo □1-3x/mo □1x/week □several x’s/week □Every day

Do you use any street drugs or misuse prescription drugs? □Yes □No

Names of Drug(s)Frequency of UseNames of DrugsFrequency of Use

______

D. Treatment Information

Please describe the main concern(s) that have prompted you to see me now? ______

______

How have these concerns evolved over time? ______

______

Please indicate your major life stressors of the past 12 months:

□Serious injury or illness □Death of a close friend or family member □Peer pressure

□Major illness in family □Gain of new family member □Divorce/Separation

□ Trauma □Relationships□Other

Please describe what you would like to be different in you life when you are done with therapy?

______

Have you ever received psychological or psychiatric counseling before? □Yes □No

When?

______

Have you ever been prescribed medication for a psychiatric or emotional problem? □Yes □No

When?Prescribing Clinician? What Medication? For What? Results?

______

Have you ever been hospitalized for a psychiatric or emotional health reason? □Yes □No

When?Where? For What Reason? Outcome?

______

Have you ever been in a drug or alcohol treatment program? □Yes □No

□Inpatient □Outpatient

Where? How Long? Outcome?

______

E. Social/Relationship Information

Please indicate any of the following that you have experienced:

□Death of MotherYour age at occurrence _____

□Death of FatherYour age at occurrence _____

□Death of ChildYour age at occurrence _____

□Death of SiblingYour age at occurrence _____

□Desertion by MotherYour age at occurrence _____

□Desertion by FatherYour age at occurrence _____

□Divorce of ParentsYour age at occurrence _____

□Sexual Abuse□Emotional Abuse□Physical Abuse

□Violence in the Family□Mental Illness of a family member

How do (did) you get along with your family of origin members? ______

Mother? ______

Father? ______

Siblings? ______

Please list the first names of your significant friends and indicate how long you have had these relationships:

First NameHow Long?How often do you see this person?

______

F. Other

Is there anything else you think I should know about prior to our beginning your treatment?

______