Minor Client Information Form - Centerpoint Counseling (Page 2 of 4) in pdf

Client/Child Name: _____________________________

Therapist:_________________________

Marital Status Married

Remarried

Single

Separated

If Divorced: date(s) final ___________________

of parents:

Divorced

Divorced/Single

Divorced/Dating

Age of child at separation(s)________________



1. Who does child talk to when they need positive, emotional support?

Mother

Father

Adult Relative

Friend

Sibling

Teacher

Other_________________

2. Has child ever been involved on any of the following services?

Support Groups Treatment Program Mental Health Counseling Anger Mgmt. Classes

Family Counseling Other_________________

3. Please list any physical disabilities your child may have.________________________________________

__________________________________________________________________________________________

4. Please list any medications your child may currently be taking and for what reason.

Medication(s)_____________________________________Reason____________________________________

5. Please list any health concerns you have about your child. ______________________________________

__________________________________________________________________________________________

6. Briefly describe your child’s current school experience (i.e. relationship with teachers, grades and

school work, concentration, relationship with peers, etc…).

__________________________________________________________________________________________

7. Briefly describe how your child is currently functioning at home (i.e. relationship with sibling/s,

relationship with parent/s, etc…).

__________________________________________________________________________________________

8. Briefly describe your child’s current peer relationships (in and outside of school).

__________________________________________________________________________________________

9. As a parent, what do you believe are the greatest challenges for your child currently?

__________________________________________________________________________________________

10. Please list the members of your current household (In order of age).

Name

Age

Relationship

(i.e. mother, step-father, child #)

__________________________________________________________________________________________

Minor Client Information Form - Centerpoint Counseling Page 2

Related Articles

Related forms

Related Categories