Child's Name *

First Name

Last Name

Parent's Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's Cell Phone

(###)

###

####

Parent's Work

(###)

###

####

Other Phone

(###)

###

####

Child's Date of Birth

MM

DD

YYYY

Father's Date of Birth

MM

DD

YYYY

Mother's Date of Birth

MM

DD

YYYY

Current Family Stressors

Check all that apply

Chronic illness of family member

Death of significant person

Family member absent

Family member disbility/major accident/illness

Family member emitional problems

Financial Problems

Moved a lot

Frequent Arguing

Divorce

Other

Current Concerns

Please mark the following items that apply.

Abuse (physical, emotional, sexual)

Adjustment to life changes (moving, getting marred or divored, aging, etc...

Drug or alcohol use (both legal and illegal drugs)

Eating problems (purging, bingeing, overeating, hoarding, severely restricting diet)

Family or Stepfamily relationship problems

Feeling angry or irritable

Feeling anxious (nervous, clingy, fearful, worried, panicky, obsessive-comulsive, lacking trus, etc.)

Felling sadness or depression NOT related to grief

Feeling sadness or depression realted to grief

Health concerns (physical, complaints and/or medical problems

Illegal behaviors (runaway, stealing, fire setting, truancy, etc)

Non-family realtionship problems (co-workers, peers, etc)

Parent-Child realtionsip problems (discipline, adoption, single parent, etc)

Sexual concerns (inaapropriate acting out, pornography, etc)

Sleep problems (nightmares, sleeoing too much/roo little, etc)

Suicidal Ideation (thoughts of death, wanting to die)

Unusal behavior (bizarre actions, speech, compulsive behaviors, tics, motor behavior problems, etc)

Other