Child's Name Date Of Birth MM slash DD slash YYYY Personal HistoryWhat is the reason you are coming in for counseling? Is there something specific, such as a particular event? If this is due to a specific event, when did it start or happen? How is your life affected by this issue? Please be as detailed as you can.What do you think you need the most help with right now?Please rank your concerns in the following areas on a scale of 1 to 10 (0 = No problems and 10 = Major problems). You may use the same number for more than one area.Depression Anxiety/Worry Parents Sex School Substance Use Legal Anger Issues Suicidal Thoughts Trouble eating food School and Social FunctioningAre you currently in school? If so, what grade are you in?When did/do you attend class?If you are attending, what is school like for you?If attending, what school do you go to? What was your grade point average last report card? Are these grades better or worse than usual? Have you ever attended any special classes (i.e., resource program, gifted programs)?Do you have a learning disability? If so, what is the disability? Yes No Untitled During the past school year, about how many days were you absent when you were supposed to be in school?Have you ever been suspended or expelled from school? If yes, please share additional details.Have you ever been in trouble at school related to an alcohol or other drug problem? If yes, please share additional details. More About YouWhat do you like to do for fun or enjoyment? Do you have any hobbies that you enjoy regularly? Do you prefer your enjoyment alone, with others, or both?Are you sexually active? Yes No Do you practice safe sex? Yes No Do you currently drink alcohol? If so, describe the type, amount, and how often (daily, weekly, monthly, etc.). Yes No Untitled Do you smoke cigarettes or use any nicotine products? If so, what and how often? Yes No Untitled Do you currently use recreational drugs? If so, describe type, amount, frequency Yes No Has your drinking or drug use ever caused problems in your family, relationships, or job? Have you ever been arrested for a D.U.I or other drug related offense? If yes, please give dates and details. Yes No Is it difficult for you to stop or control the amount you drink or use? Yes No If you feel you have a problem with alcohol or drugs, would you like help? SymptomsPlease check any symptoms that you currently experience or have experienced, and indicate when you experienced them. Headaches Feeling isolated Restlessness Suicidal thoughts Dizziness Suicidal plans Pain Attempted suicide Excessive anger Crying frequently Less need for sleep Anxiety Excess energy Frequent worrying Elated mood Fears Excessive spending Panic attacks Racing thoughts Avoiding places of situations due to fear or panic/anxiety Feeling irritable Concentration problems Feeling wired Feel that others are plotting against you Mood swings Constant suspicion or distrust Grandiose thoughts Hearing voices that others do not hear Impulsive behavior Seeing things others do not see Confusion Physical abuse Alcohol craving Sexual abuse Drug craving Emotional/verbal abuse Eating problems Sexual problems Weight gain Relationship problems Weight loss Family conflict Loss of appetite Fears of losing control Difficulty getting to sleep Unwanted thoughts or behaviors Appetite changes Feeling the need to do/repeat things Difficulty staying asleep Obsessive/repetitive thoughts Frequent nightmares Unusual thoughts Low energy Strange experiences Unable to have fun Thoughts of someone physically harming you Decreased pleasure Thoughts of physically harming someone Feeling worthless Violent or aggressive behavior Feeling hopeless Psychiatric HistoryHave you seen a mental health professional before? If so, please specify dates, the reason for counseling, and your experience. What was your diagnosis, if any? Yes No If applicable, list all psychotropic medications you are currently taking, for how long, and for what reason. What is the dosage of each? What time of day do you take it (morning, evening, bedtime)? Does it help?If taking prescription medication, who is your prescribing doctor? Please include type of doctor, name, and phone number.Do you have, or have you ever had, suicidal thoughts? If yes, when? If yes, how would you end your life? No, I have never had suicidal thoughts. If taking prescription medication, who is your prescribing doctor? Please include type of doctor, name, and phone number.Have you ever attempted suicide? Please list all attempts and your age when each happened, starting from the most recent event to the oldest event. If yes, when? If yes, how did you do it? No, I have never attempted suicide. If taking prescription medication, who is your prescribing doctor? Please include type of doctor, name, and phone number.Have you ever been hospitalized for a psychiatric issue? If yes, please describe why, when, and the length of your stay. Yes No, I have never been hospitalized for a psychiatric reason do it? If taking prescription medication, who is your prescribing doctor? Please include type of doctor, name, and phone number.Do any family members struggle with the following challenges? Please specify which family member.Challenges Learning challenges/disability Depression/Bipolar Disorder Alcoholism/drug addiction Anxiety/panic attacks Trauma (sexual assault, combat, abuse, etc.) Suicide attempts Eating disorders (Anorexia/Bulimia) Hyperactivity/ADHD Other (Please Specify) Family Member Family HistoryPlease describe your relationship with your motherPlease describe your relationship with your fatherDo you have siblings? Yes No If so, please describe your relationship with them.If you are in a relationship, please describe the nature of the relationship and months or years together.Who do you know that you would consider your closest sources of support or your "inner circle" (e.g., grandparent, aunt, uncle, friend, cousin, teacher, etc.)?What else would you like me to know?
