Thoughtful Counseling LLC
Child/Teen’s Name: ____________________________ Date of Birth: __/___/___
Age: ____ Sex: _____ Race: ____
School: __________________________________________ Grade: ________
Grades Retained _________________________________________________
Describe Child’s Academic Progress __________________________________
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Extra-Curricular Actives/Hobbies: ____________________________________
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Mother’s Name:___________________________________________________
Father’s Name: ___________________________________________________
Step Parent’s Name(s) (if applicable)_________________________________
Step Parent’s Name(s) (if applicable)_________________________________
Child’s Address: __________________________________________________
Home phone: _____________________
Cell phone: _____________________
Work phone: _____________________
Child is currently living with: _________________________________________
Please describe the situation/symptoms for which you are seeking help: ______
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What would you like to see accomplished in your child’s counseling: _________
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Thoughtful Counseling LLC
Has your child previously participated in counseling? (Circle) Yes / No
If Yes, when _______________________ where________________________
Name of Therapist: ________________________________________________
What was the result? _____________________________________________
Please list any current medical problems/medications: ____________________
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Past medical/developmental/educational problems/medications: ____________
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Allergies ______________________________________________________
Pediatrician’s Name: ______________________________________________
Dentist Name: ___________________________________________________
Child’s Siblings Names and Ages____________________________________
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If child is adopted, please give pertinent information:______________________
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Family Stressors (current factors that are a source of stress in the family): ____
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Please list any developmental problems (feeding, sleep, anxiety, motor/language/social developmental problems, toilet training, etc.) _________
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Please list any social/emotional problems (being bullied, bullying, sleep, anxiety, or fears, etc.) ______________________________________________________
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Thoughtful Counseling LLC
Family Structure: (who lives in the current household/relationship to the child)
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Family Development: (marriages, separations, divorces, deaths, traumatic events/losses)
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Parent’s Current Marital Status: ______________________________________
Age:____________ Work status: _____________________________________ Highest grade completed in school: ___________________________________
Learning/Behavior problems:_________________________________________
Marriages: How many? _____________ How long? ______________________
Medical problems: _________________________________________________
Childhood atmosphere (family position, abuse, illness, etc.) _________________
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Please specify any mental health treatment, alcohol/drug abuse history, psychiatric treatment, suicide attempts, and hospitalizations: ____________________
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Thoughtful Counseling LLC
Age: ____________ Work status: _____________________________________ Highest grade completed in school: ___________________________________
Learning/Behavior problems:_________________________________________
Marriages: How many? _____________ How long? ______________________
Medical problems: _________________________________________________
Childhood atmosphere (family position, abuse, illness, etc) _________________
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Please specify any mental health treatment, alcohol/drug abuse history, psychiatric treatment, suicide attempts, hospitalizations:____________________
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Name of person filling out form: ______________________________________
Relationship to child or adolescent:____________________________________
Who Referred you ?________________________________________________
May I send a thank-you note? Yes/No
If yes, please provide an address or phone number for the person:
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