<p> Debbie Granick, MPH, LCSW, RN Client Information Form for Parents of Minors</p><p>Today’s Date:______</p><p>I Basic Information Parent names:______DOB (mom) :_____/_____/_____ (dad) _____/_____/_____</p><p>Child’s Name: ______Child’s Date of Birth: ______</p><p>Preferred parent phone (s): ______/______Alternate phone: ( ) ______Address (mom or both) (street, city, state, zip) ______(Dad) ______Email(s) for parents:______/______</p><p>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</p><p>If it is okay for me to contact your child directly regarding appointments, please provide their: cell number:______Email:______</p><p>Parent marital status (circle one): Single Married Living with someone Divorced Separated Widowed </p><p>Occupation(s):</p><p>How did you hear about me? </p><p>May I thank someone for your referral (circle one)? Yes No</p><p>If yes, please provide name and contact information (if known): II Family Information</p><p>What are the names and ages of your other children?</p><p>What behaviors or issues are you struggling with? 1) 2) 3) 4)</p><p>What approaches/techniques have you tried so far to improve the situation? What was the result?</p><p>How do you and your co-parent (if applicable) approach this situation similarly? Differently?</p><p>What do you hope to accomplish with counseling and coaching? 1) 2)</p><p>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)</p><p>Have you sought professional help for this issue in the past? Yes No If yes, who did you see and what was the outcome?</p><p>Is your child under the care of a Psychiatrist? Yes No If yes, what is her/his name and phone number?</p><p>If yes, when is the last time your child had a visit?</p><p>If yes, does your child have any specific health or mental health diagnosis?</p><p>What is the name/phone number of your child’s Pediatrician or general health provider?</p><p>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)--</p><p>Please list names and dosages of any current medications and reasons for taking them:</p><p>List recent or present significant illnesses, surgeries, injuries or hospitalizations:</p><p>What specific concerns, if any, does your child’s school have with your child?</p><p>What specific concerns, if any, does your child’s doctor have with your child?</p><p>Has your child ever been the victim of (circle any that apply): physical abuse emotional abuse sexual abuse verbal abuse</p><p>If yes, did he/she receive any treatment or attention for the above?</p><p>Has your child ever witnessed (circle any that apply): physical abuse emotional abuse sexual abuse verbal abuse</p><p>Has your child ever attempted or spoken significantly about suicide? If yes, please describe and provide date and treatment, if received.</p><p>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</p><p>Please let me know any concerns or questions you may have about counseling or coaching:</p><p>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</p><p>__ 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</p><p>Thank you for providing me with this information. I look forward to working with you to reach your goals!</p>