Debbie Granick, MPH, LCSW, RN

Debbie Granick, MPH, LCSW, RN Client Information Form for Parents of Minors

Today’s Date:______

I Basic Information Parent names:______DOB (mom) :_____/_____/_____ (dad) _____/_____/_____

Child’s Name: ______Child’s Date of Birth: ______

Preferred parent phone (s): ______/______Alternate phone: ( ) ______Address (mom or both) (street, city, state, zip) ______(Dad) ______Email(s) for parents:______/______

Is it okay for me to email you regarding appointments? Y N Is it okay for me to call you regarding appointments? Y N Is it okay for me to text you regarding appointments? Y N May I send you my quarterly wellness email? Y N

If it is okay for me to contact your child directly regarding appointments, please provide their: cell number:______Email:______

Parent marital status (circle one): Single Married Living with someone Divorced Separated Widowed

Occupation(s):

How did you hear about me?

May I thank someone for your referral (circle one)? Yes No

If yes, please provide name and contact information (if known): II Family Information

What are the names and ages of your other children?

What behaviors or issues are you struggling with? 1) 2) 3) 4)

What approaches/techniques have you tried so far to improve the situation? What was the result?

How do you and your co-parent (if applicable) approach this situation similarly? Differently?

What do you hope to accomplish with counseling and coaching? 1) 2)

What specific behavior changes (in the child, you, your marriage, your family, etc.) will make you feel that improvement has been made? 1) 2) 3) 4)

Have you sought professional help for this issue in the past? Yes No If yes, who did you see and what was the outcome?

Is your child under the care of a Psychiatrist? Yes No If yes, what is her/his name and phone number?

If yes, when is the last time your child had a visit?

If yes, does your child have any specific health or mental health diagnosis?

What is the name/phone number of your child’s Pediatrician or general health provider?

When was your child’s last visit? Does your child have any: (if yes, please describe)  Physical limitations--  Health-threatening food allergies--  Developmental concerns (current or prior)--

Please list names and dosages of any current medications and reasons for taking them:

List recent or present significant illnesses, surgeries, injuries or hospitalizations:

What specific concerns, if any, does your child’s school have with your child?

What specific concerns, if any, does your child’s doctor have with your child?

Has your child ever been the victim of (circle any that apply): physical abuse emotional abuse sexual abuse verbal abuse

If yes, did he/she receive any treatment or attention for the above?

Has your child ever witnessed (circle any that apply): physical abuse emotional abuse sexual abuse verbal abuse

Has your child ever attempted or spoken significantly about suicide? If yes, please describe and provide date and treatment, if received.

Does your child currently live, or has he/she ever lived, with someone with a problem with alcoholism, drug abuse, or mental illness? Yes No If yes, who? Please describe situation

Please let me know any concerns or questions you may have about counseling or coaching:

Is there anything else you would like me to know? For parents of kids over 9 only: Please respond to each of the following symptoms by indicating in the boxes how much of a problem they have been in the last two weeks. Use the following scale: 4- serious problem 3- moderate problem 2- mild problem 1- not a problem at all

__ Depressed mood __Poor judgment __Obsessive/compulsive behavior __Excessive worry or stress __Low self esteem __Significant weight change __Thoughts of hurting him/herself __Social withdrawal __Thoughts of hurting someone else __Loss of interest in things __Arguing excessively __Panic attacks __Excessive use of alcohol __Flashbacks __Excessive use of other drugs __Difficulty concentrating __Phobias/fears/nightmares __School challenges or failure __Easily annoyed __Difficulty with friends __Not thinking clearly/confused __Difficulty with family __Excessive anger __Legal trouble __Appetite changes (up? down?) __Sexual risk taking __Sleep problems __Other risk taking

Thank you for providing me with this information. I look forward to working with you to reach your goals!