Intake - Adolescent - Anxiety & Depression Therapy - Orange County CA

Legal Name of Youth *

First

Last

Nick Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number of Parent *

Name of Parent of this phone # *

Can a message be left at this phone #? *

Email of Parent *

Birth date of Youth *

Youth lives with *

Current Age of Youth *

Youth's parents are *

Parent #1 Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can a message be left at this phone #? *

This parent is *

This parent is employed outside the home *

Parent #2 Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Can a message be left at this phone #? *

This parent is *

This parent is employed outside the home *

Add'l Caregiver Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Relationship to Youth *

Does caregiver live with youth? *

Why are you seeking counseling for the youth? *

Has the youth already been in counseling? *

How has the family tried to resolve the youth's issues? *

If yes, please give the counselor's name and city located. *

Sibling Name *

Sibling Age *

Sibling Gender *

Sibling Age *

Sibling Gender *

Sibling Age *

Sibling Gender *

Sibling Age *

Sibling Gender *

Does this sibling live at home with youth? *

Does your youth use recreational drugs? *

If yes, please explain *

Name of current school with city. *

Current Grade *

Most current school year performance *

Previous school year performance *

Most current school year behavior *

Previous school year behavior *

List any additional Medical Conditions not covered above. *

Name of Medication *

Dose *

Reason for Taking *

Primary Physician *

Psychiatrist *

Other Medical Specialist *

Phone Number *

Check who the Youth has for social support *

Neighborhood Friends School Friends Family

. *

Faith Based Friends Community Group/Park & Rec Lacks Good Social Support

Which Cultural / Ethic group does your youth belong? *

Has the youth experienced any problems due to his/her cultural/ethnic group? Please describe *

If parents Separated/Divorced what are the custody arrangements? *

Do the Parents have Joint Custody? *

Has the Youth ever been arrested *

If yes, what were the charges? *

Please share any information you feel would be helpful to me, that hasn't been covered above. *

*If Other, please list which Insurance Company you have *

Insurance Member Number - it's important to include this as your coverage needs to be confirmed. *

Intake - Adolescent (ages 12 - 17)Please complete this form prior to our first session. All information is protected by confidentiality. ** This is a Secure form. All information sent will be encrypted.

Intake - Adolescent (ages 12 - 17)
Please complete this form prior to our first session. All information is protected by confidentiality.
** This is a Secure form. All information sent will be encrypted.