<p> Gigia Demko, MA, LMHC 2118 Caton Way SW Olympia, WA 98502 PH: 360-402-7527 Fax: 360-352-3289 Child Information Date:</p><p>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: </p><p>Parent: DOB: Parent: DOB: Current Caregiver(s): Caregiver(s) DOB(s): </p><p>B. Referral Information Who gave you my name to call? May I have your permission to thank this person for the referral? □ Yes □ No</p><p>C. Insurance Information Relationship to insured? □ Self □ Spouse □ Child □ Other Insured’s Name (if not self): DOB: SSN: Insurance Company: </p><p>D. Family Information Number of siblings, their names and ages:</p><p>How does your child get along with each sibling? </p><p>1 Child is currently living with □ biological mother □ biological father □ step-mother □ step-father □ foster mother □ foster father □ adoptive mother □ adoptive father □ other ______</p><p>Father’s Family History of: □ Depression □ Suicide Attempts □ Anxiety □ Eating Disorders □ Mental Illness □ Violence □ Sexual Abuse □ Emotional Abuse □ Alcoholism □ Drug Addiction</p><p>□ Chronic Illness (please explain) ______□ Other ______</p><p>Mother’s Family History of: □ Depression □ Suicide Attempts □ Anxiety □ Eating Disorders □ Mental Illness □ Violence □ Sexual Abuse □ Emotional Abuse □ Alcoholism □ Drug Addiction</p><p>□ Chronic Illness (please explain) ______□ Other ______</p><p>E. Medical Information Pediatrician/Family Physician: Phone: Last Exam: Major (or Chronic) Operations/Illnesses/Injuries </p><p>Medications Dosage(s) Frequency Effectiveness Prescribing Physician</p><p>2 ______</p><p>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: </p><p>Length of time symptoms have persisted: Past Therapists/Psychiatrists: </p><p>F. Other</p><p>Any Recent Changes?: </p><p>What brings you here today?: </p><p>Is there anything else I should know about your child prior to beginning treatment?</p><p>DIAGNOSTIC IMPRESSION: For Clinician to complete: AXIS I </p><p>AXIS II</p><p>3 AXIS III</p><p>AXIS IV </p><p>AXIS V GAF (current): GAF (past year):</p><p>4</p>