Gigia Demko, MA, LMHC

Gigia Demko, MA, LMHC 2118 Caton Way SW Olympia, WA 98502 PH: 360-402-7527 Fax: 360-352-3289 Child Information Date:

A. Identification Information Name: DOB: SSN: Address: City: State: Zip: Phone (Home): Phone (cell): School child attends: Grade: IEP: Y/N if Yes what subjects: School Telephone: Teacher:

Parent: DOB: Parent: DOB: Current Caregiver(s): Caregiver(s) DOB(s):

B. Referral Information Who gave you my name to call? May I have your permission to thank this person for the referral? □ Yes □ No

C. Insurance Information Relationship to insured? □ Self □ Spouse □ Child □ Other Insured’s Name (if not self): DOB: SSN: Insurance Company:

D. Family Information Number of siblings, their names and ages:

How does your child get along with each sibling?

1 Child is currently living with □ biological mother □ biological father □ step-mother □ step-father □ foster mother □ foster father □ adoptive mother □ adoptive father □ other ______

Father’s Family History of: □ Depression □ Suicide Attempts □ Anxiety □ Eating Disorders □ Mental Illness □ Violence □ Sexual Abuse □ Emotional Abuse □ Alcoholism □ Drug Addiction

□ Chronic Illness (please explain) ______□ Other ______

Mother’s Family History of: □ Depression □ Suicide Attempts □ Anxiety □ Eating Disorders □ Mental Illness □ Violence □ Sexual Abuse □ Emotional Abuse □ Alcoholism □ Drug Addiction

□ Chronic Illness (please explain) ______□ Other ______

E. Medical Information Pediatrician/Family Physician: Phone: Last Exam: Major (or Chronic) Operations/Illnesses/Injuries

Medications Dosage(s) Frequency Effectiveness Prescribing Physician

2 ______

Symptoms: __ depressed __Insomnia __agitation __excess worry __Irritable Mood __ nightmares __poor concentration __anxious mood __Feelings of worthlessness __low energy __poor hygiene __panic attacks __Excessive feelings of guilt __poor appetite __poor memory __not wanting to leave house __thoughts of death __excessive weight gain __indecisiveness __bed wetting __Suicidal ideation __excessive weight loss __isolation __daytime potty accidents Other Symptoms:

Length of time symptoms have persisted: Past Therapists/Psychiatrists:

F. Other

Any Recent Changes?:

What brings you here today?:

Is there anything else I should know about your child prior to beginning treatment?

DIAGNOSTIC IMPRESSION: For Clinician to complete: AXIS I

AXIS II

3 AXIS III

AXIS IV

AXIS V GAF (current): GAF (past year):