Adolescent Questionnaire
Name: *
Your answer
DOB: *
Your answer
Nickname/Preferred Name: *
Your answer
Name of parent/guardian(s): *
Your answer
Address: *
Your answer
City/town/Zip: *
Your answer
Adolescent phone: *
Your answer
Parent/Guardian Phone: *
Your answer
Religion/Spiritual Practice: *
Your answer
Emergency contact (must be over 18): *
Your answer
I understand that The Wellness Room staff will contact my emergency only in the case of an emergency. The Wellness Room staff may be required to share limited clinical information with my emergency contact. (Sign below) *
Your answer
Name and telephone number of primary care doctor: *
Your answer
Employed? (adolescent) *
Immediate family members (list all immediate family members; please list even if they do not live with you): *
Your answer
What are your goals for our time together? *
Your answer
What have you tried on your own to solve your concerns? *
Your answer
What do you imagine will be the first sign that our work together is successful? *
Your answer
Please list any other services/agencies/professionals involved with your care (such as psychiatrist/nurse prescriber, hospital, other medical professionals, current therapist or special educator supports/school supports): *
Your answer
Please list prior therapists, psychiatrists, or mental health treatments including their names and approximate dates of service: *
Your answer
Please let us know what was beneficial with these prior therapists and what was NOT beneficial: *
Your answer
Please list any physical, mental health issues, or substance use/abuse (past or present) for family members. *
Your answer
Please list all medication and/or herbal supplements you are currently using or have used in the past. *
Your answer
Please describe your support network (include family members, friends, religious community, professionals, pets): *
Your answer
Sleep Habits
Do you have any trouble with sleep? *
Do you experience daytime sleepiness? *
How many hours do you sleep most nights? *
Your answer
How long does it take you to get to sleep once you lay down? *
Your answer
If you wake up in the middle of the night, how long does it take you to get back to sleep? *
Your answer
Is your current sleep pattern the same or different from your normal? *
Your answer
Here is a list of common areas of discussion. Please consider if you would like to discuss any of them during our time together (check all that apply)
Please use this space to share anything else important that you think we should know about you.
Your answer
Signature *
Your answer
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