This Paperwork Is Optional. Most Teens Find It Helpful to Share with Me a Little Bit About
This paperwork is Optional. Most teens find it helpful to share with me a little bit about themselves. You can write as much or as little as you like.
Name ______Date______
Cell phone ______Email ______
Best way to get in contact with you ______
Are you seeking individual counseling for yourself, family counseling, or a combination of the two?
Information I need to tell you
My office cell phone is 425) 877-9808 and my email is . These are the best ways to reach me. I return phone call and emails usually by the end of the day.
If you happen to be in a crisis and cannot immediately reach me, I am ethically required to let you know about other resources. There are two 24-hour crisis lines you can call at 206) 461-3222 or 425) 258-4357, or you can call 911.
Confidentiality: Firstly I want to reassure you that everything you share with me is confidential. There are however a few exceptions. I am legally required to contact authorities if you are the victim of physical, sexual or emotional abuse. I am also legally required to intervene if you are a danger to yourself or others. Also, I have professional boundaries with two other issues. The first pertains to drug and alcohol addiction. I refer any client, adolescent or adult, that has an addiction to drugs or alcohol to substance abuse treatment. Counseling is ineffective with someone that is actively addicted. If you need me to define what addiction is, please let me know. The second boundary pertains to teen pregnancy. I’ve worked with quite a few pregnant teens over the years and believe parents should be involved in helping a teen decide how to cope with a pregnancy. With regards to your family, it is my practice is to talk with you about information you would like me to share and not share with your parents/family. If you have any questions about confidentiality, please be sure to ask.
ABOUT YOU:
Please tell me what concern brings you to counseling? Be as detailed as you like(when the problem started, how often it occurs, what’s contributing to the problem). Use the reverse side if needed.
What do you hope to gain from counseling?
Have you gotten help for this problem before? (If yes, please tell me about it)
What do you consider to be some of your strengths?
What do you consider to be some of your challenges?
What are your favorite hobbies, activities…. (such as sports, music, computers, dancing, school activities….)?
How do you feel about school?
How are you doing in school?
Do you have a job or specific chores?.
About how many close friends do you have?
About how many times a week do you do things with friends outside of regular school hours?
Can you describe one of your closest friends?
Are any of these stressors impacting your family at this time? Please describe any checked.
□ School problems□ Illnesses
□ Parental conflict
□ Financial stress
□ Sibling conflict
□
Tell me about your family, who are / □ Death of a family member or someone close
□ Drug or alcohol problems
□ Abusive behavior
□ Struggles between you and your parents
□ Changes in household or frequent moving
□ Other, please describe:
you close to, your family’s strengths …….
CHECKLIST
Below is a list of mental health concerns. Please put one or two checks next to any that describe you:
No Check = NOT TRUE 1 √= Somewhat True 2 √√ = Very True
□ I argue alot□ I fail to finish things I start
□ I have trouble concentrating, paying attention
□ I have trouble sitting still
□ I disobey my parents
□ I feel self-conscious or easily embarrassed
□ I feel worthless or inferior
□ I obsess about food and dieting
□ I feel too fearful or anxious
□ I feel lonely or isolated
□ I am a perfectionist
□ I feel too guilty
□ I am stubborn
□ I use laxatives
□ I have recently lost friends / □ I have negative thoughts about myself
□ I am often moody or irritable
□ I exercise more than two hours a day
□ I worry alot
□ I am afraid that I will hurt myself
□ I am sexually active
□ My moods change suddenly
□ I have thoughts about killing myself
□ I have negative thoughts about my body
□ I threaten to hurt people
□ I am unhappy, sad or depressed
□ I make myself vomit
□ I feel hopeless about the future
□ I act without stopping to think
□ I am no longer interested in activities I use to enjoy
Have you ever been physically abused or assaulted? □ No □ Yes
Have you ever been sexually abused or assaulted? □ No □ Yes □ I don’t know
Substance Use
Do you smoke cigarettes? □ No □ Yes If yes, cigarettes per Day _____ Began at what age?_____
Do you drink alcohol? □ No □ Yes If yes, how often: ______
Check all the apply: □ Beer □ Wine□ Hard Liquor
Have you ever usedany street drugs? □ No □ Yes If yes, what drugs
Please feel free to elaborate on your concerns or anything that was not brought up on this form:
Is there anything you would like to know about me?
For Fun: Complete these sentence stems to share a little more about you
My favorite music is
My favorite website is
My favorite TV show or movie is
If I could go anywhere in the world, I’d go
If I could be an animal, I’d be
The animal I would hate to be is
My happiest or fondest memory is
I wish I could tell ______that
(person’sname)
I wish ______would tell me
(person’s name)
One thing I like about my personality is
One thing I like about my body is
A person I admire is
A good friend is someone who
My friends tell me
My parents tell me
If I had a superpower, my superpower would be
If I had a magic wand