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Counseling Intake Form (Minors)
Please complete the form below if you’re interested in my Counseling Services!
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Child/ Adolescent Name
*
Child/ Adolescent Date of Birth
*
Child/ Adolescent Current Grade
*
Child/ Adolescent Current Name of School
*
Parent/ Guardian Phone Number
*
Parent/ Guardian Mailing Address
*
Mother's Name
*
Mother's Highest Grade Level
*
If Mother is deceased, date
Father's Name
*
Father's Highest Grade Level
*
If Father is deceased, date
If the Child’s parents are not currently married, please describe below (dates of adoption, divorce, remarriage, names of step-parents, and/or other relevant information):
*
Brothers/ Sisters
*
Yes
No
If yes, please share
Are both parents in agreement with bringing him/ her for counseling?
*
Yes
No
Please describe any recent changes for your family (births, deaths, moves, accidents, etc):
*
Your Relationship to Child
*
Reason for Treatment
*
Any Previous Treatment?
*
Yes
No
If yes, please explain
How does your child/ adolescent feel about counseling at this time?
*
In what way would you like counseling to help your child/ adolescent?
*
What family members are likely willing to participate in your child’s counseling?
*
Did your child generally meet developmental milestones (i.e., walking, talking, etc.) on time?
*
Please describe any difficulties your child/adolescent is having in school.
*
Has your child ever been psychologically tested?
*
Yes
No
Does your child/ adolescent attend church?
*
Yes
No
What role does spirituality play in his/ her life?
*
On-going Medical Conditions
*
Yes
No
If yes, please explain
Is your child/adolescent taking any prescription medication?
*
Yes
No
Any Side Effects?
*
Yes
No
If yes, please explain
Has your child had a hearing exam?
*
Yes
No
Has your child had an eye exam?
*
Yes
No
Were any problems discovered for either of the above?
*
Yes
No
If yes, please explain
Has your child used drugs or alcohol?
*
Yes
No
Family history of substance abuse?
*
Yes
No
Please share any areas of concern
*
Please describe your daughter/son in a few sentences (areas of relative strength or giftedness, challenges, etc.)
*
Is there anything that would be good for your counselor to know?
*
Have you thoroughly reviewed the information above?
*
Yes
No
Submit
Home
About
Coaching Services
Coaching Intake Form for Adults
Confidence Coaching Inquiry Form for Minors
Counseling Services
Counseling Intake Form for Adults
Counseling Intake Form for Minors
Contact
Shop
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