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4. CHILD / ADOLESCENT Assessment form

4. Child or Adolescent Assessment

Child's Name *

Date *

Child's Date of Birth *

Grade in School *

Parent or Guardian's Phone Number *

Parent or Guardian's Email Address *

Who referred you to this office? *

How old is your child? *

What are your current concerns related to you child today? *

What is the quality of your family relationship at this time? *

Are there school issues that you are concerned about? If so, please describe *

Are there drug/alcohol issues related to your child/adolescent? If so, what are they? *

Is your family involved with the Department of Human Services or Juvenile Court? If so, how and why? *

What brings your child to counseling? (Check all that apply) *

Depression

Family

School

Anxiety

Divorce / Separation

Grief

Adjustment

Physical Abuse

Sexual Abuse

Other issues; please describe in as much detail as possible *

Is your child experiencing any of the following? (Check all that apply) *

Guilt

Panic / Anxiety

Sexual Issues

Trouble Sleeping

Wetting / Soiling

Poor Boundaries

Poor Appetite

Loss of Interest

Trouble Concentrating

Feelings of Hopelessness

Tantrums

Touching Others Inappropriately

Fatigue

Irritability

Worry

Aggression

Nightmares

Other significant problems/behaviors? Please explain *

Has your child ever had any counseling before? *

Yes

With whom? *

When? *

For what issues? *

Have others in your family received counseling services before today? *

Yes

What for, where and when? *

Who in your family participated in counseling sessions? *

Is your child taking any medication currently? *

Yes

What medication and dose? *

Who monitors this medication? *

Does anyone in your family have issues with drugs/alcohol? *

Yes

Please describe *

Is there a family history of mental health issues, drug and alcohol use, domestic violence or criminal activity? *

Yes

Please describe *

Is there anything else about your child and your family that might be helpful to the counseling process?

Guardian's Signature - Child or Adolescent Assessment Form *

Clear

Today's *

Guardian's Full Name *

Relationship to Child *

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Full Name *

Phone Number *

Email *

Reason for Contacting (Select One) * Reason for Contacting (Select One)

Message *

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