Date *

Time *

Who is completing this document? *

Client's Name *

Parent(s)/Guardian(s) *

Date of Birth *

Gender *

How did you hear about Theraplace? *

Name of Primary Care Physician and Clinic *

Do you give permission for ongoing regular updates to be provided to your Primary Care Physician? *

Primary reason(s) for seeking services *

Which school does the child attend? *

Name of teacher(s) *

Current grade *

Does the child have any special programming (ex. Speech, OT, 504, IEP, Accelerated Classes)? *

Additional Information Relating to Education (ex. change in school, homeschooling program, etc).

Living Situation - Please check all that apply. *

With whom does the child live? List people, and pets if applicable. *

How important are spiritual or religious beliefs to the child? *

Is the child affiliated with a spiritual or religious group? If yes, which one? Type "no" if they are not affiliated with a spiritual or religious group. *

Would they like spiritual or religious beliefs incorporated into counseling? *

To which cultural or ethnic group does the child belong? *

Are they experiencing any problems due to culture or ethnicity? If yes, please describe. Type "no" if they are not experiencing any problems due to culture or ethnicity. *

Other cultural/ethnic information:

Describe areas of interest or hobbies (ex. reading, crafts, sports, outdoor activities). *

Describe the child's strengths and resources. What do they do well? Who do they consider supportive (pet, family, friend, therapist)? Which areas of their life are stable? *

Medical/Physical Health - Please check all that apply. *

Please describe any recent changes in their physical health. Type "none" if no recent changes have occurred. *

Does the child exercise? If yes, please describe what kind of exercise, how many days per week and how much time each day. Type "no" if they do not exercise. *

Did the child's mother experience any complications during the pregnancy or birth? If yes, please explain. Type "no" if there were no complications. *

Please describe family medical history (ex. history of cancer, diabetes, high blood pressure, etc.). *

Please list currently prescribed medication, including name of prescribing physician. Indicate if they experience any side effects from currently prescribed medication. Type "none" if they are not currently prescribed medication. *

Please list any current over-the-counter medication (ie. medication that does not require a prescription from a physician), including vitamins or herbal supplements. Indicate if they experience any side effects from prescribed medication. Type "none" if they are not taking over-the-counter medication. *

Please list past prescribed medication, including name of prescribing physician. Indicate if they experienced any side effects from prescribed medication. Type "none" if they have not been prescribed medication. *

Are they allergic to medication or drugs? If yes, please describe. Type "no" if they have no allergies to medication or drugs. *

Please describe any legal information you would like the clinician to know (ex. custody arrangement, court case, etc.).

Does anyone in the child's family have past or present substance use? If yes, please indicate which substance(s) and the family member's relationship to the child. Type "no" if no family members have a history of substance use. *

Development *

Additional information regarding the child's development (ex. early intervention services utilized).

Maltreatment or Abuse - Please check all that apply. *

Childhood Maltreatment or Abuse - Additional information you would like your clinician to know.

Please list immediate family members, including whether they are living or deceased, and approximate ages (ex. parent, sibling, step parent, grandparent). *

Parental Information - Please check all that apply. *

Current Symptoms - Please check any behaviors and symptoms that you experience. *

Briefly discuss how the above symptoms affect the child's functioning at home, school, in the community or socially. *

History of symptoms. Please describe when the child's symptoms started, when they worsen or improve, etc. *

Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *

Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *

Does the child endorse suicidal thoughts or behavior? *

Please describe any history of suicidal ideation or self harm. Type "none" if they have not experienced suicidal ideation or self harm. *

History of Treatment - Please check all that apply. *

Please list any previous mental health diagnoses. Type "none" if they have never received a mental health diagnosis. *

History of Treatment for Family Members - Please check all that apply. *

Please list any previous mental health diagnoses for Family Members. Type "none" if family members have never received a mental health diagnosis. *

Strengths and DIfficulties Questionnaire - Please answer based on the child's behavior over the last 6 months *