Parent / Guardian Name(s)
Parent / Guardian E-Mail Address
Parent / Guardian Phone Number
May We Leave Recorded Phone Messages?
Persons That Messages May Be Left With (If Any)
Client Name
Client Age
Client Date of Birth
Client Address
Has Client Received Prior Counseling?
Name of Prior Counselor
Last Date of Prior Counseling
Reason(s) for Prior Counseling
Any Other Family Members Receiving Counseling?
If So, Which Family Members?
If Other Family Members Are Receiving Counseling, State Why & with Whom
Emergency Contact 1 (Please Provide Name, Relationship, Address, Phone #)
Emergency Contact 2 (Please Provide Name, Relationship, Address, Phone #)
Please Fill Out the Following as it Relates to the Client
State the Nature of the Problem
Most Difficult Relationship Right Now
Most Difficult Emotion Right Now
What Do You Want to Gain From Counseling?
Family Mental Health History - Select Yes / No if Any Family Members Had the Below Issues & Please List Their Name / Relationship
Alcohol / Substance Abuse
If So, Which Family Members Had Alcohol Problems?
If So, Which Family Members Had Anxiety Problems?
If So, Which Family Members Had Depression Problems?
If So, Which Family Members Had Domestic Violence Problems?
If So, Which Family Members Had Eating Disorders?
If So, Which Family Members Had Obesity Problems?
Obsessive Compulsive Behavior
If So, Which Family Members Had Obsessive Compulsive Behavior?
If So, Which Family Members Had Schizophrenia?
If So, Which Family Members Attempted Suicide?
Abused/Neglected (Physical, Emotional, Sexual)
If So, Which Family Members were Abused / Neglected?
Crisis Information
Any Current Suicidal Thoughts, Feelings or Actions?
If So, Please Explain the Suicidal Thoughts, Feelings or Actions
What is Your Current Mood Right Now? On a scale of zero (0) to ten (10), with zero meaning 'life is not worth living' and ten meaning you are very opportunistic and wonderful, what number would you give your mood?
Any Past Hospitalizations or jailings for Suicidal or Assaultive Behavior?
If So, Please Explain these Problems
Any Current Threats of Signifcant Loss or Harm? (Illness, Divorce, Job Loss, Custody, etc...)
If So, Please Explain these Threats
Medical Information
Doctor's Name, Address, Phone #
Medical Insurance Company & #
Are You Currently Taking Prescription Medication?
If So, Please List Which Prescription Medications
Have You Ever Been Prescribed Psychiatric Medication?
If So, Please List Which Psychiatric Medications
Any Problems with Eating, Sleeping, Chronic Pain, Recent Weight Changes?
If So, Please Describe
Have You Ever Experienced an Abortion?
If So, How Many?
Other Medical Problems?
Spiritual History
Do You Consider Yourself to Be Spiritual or Religious?
Any Specific Denomination?
Please Describe Your Faith
How Strong is the Influence of Chruch in Your Life?
What Are Some of Your Strengths?
What Are Some of Your Weaknesses?
Child Checklist of Characteristics
Check All That Apply
Argues, Talks Back Bullies, Intimidates, Bossy, Provokes Cheats Cruel to Animals Concern for Others Conflicts with Parents Over Rules, Money, Chores, Homework, Grades / Choices Complains Cries Easily / Feelings Hurt Dawdles, Procrastinates, Wastes Time Difficulties with New Marriage / New Family Dependent, Immature Developmental Delays Disrupts Family Activities Disbodient, Uncooperative, Doesn't Follow Rules Distractible, Inattentive, Day Dreams Dropping Out of School Drug, Alcohol Abuse Eating (Poor manners, Appetite Increase or Decrease, Overeats) Exercise Problems Extracurricular Activities Interfering with Grades Failure in School Fearful Fighting, Agressive, Hostile, Threatens, Destructive Fire Setting Friendly, Outgoing, Social Hypochondriac, Always Complaining of Feeling Sick Immature, Always Clowns Around, Has Younger Playmates Imaginary Playmates, Fantasy Independent Interrupts, Talks Out, Yells Lacks Organization, Unprepared Lacks Respect for Authority, Insults, Dares, Provokes, Manipulates Learning Disability Legal Difficulties (Truancy, Loitering, Panhandling, Drinking, Vandalism, Stealing, Fighting, Drug Sales) Likes to be Alone, Withdraws, Isolates Lying Low Frustration Tolerance, Irritability Mental Retardation Moody Mute, Refuses to Speak Nail Biting Nervous Nightmares Need for High Degree of Supervision at Home (Play, Chores, Schedule) Obedient Obesity Overactive, Restless, Out-of-Seat Behaviors, Restlessness, Fidgety, Noisiness Oppositional, Resists, Refuses, Non-Compliant, Negativism Prejudiced, Bigoted, Insulting, Name Calling, Intolerant Pouts Recent Move, New School, Loss of Friends Relationships with Brothers / Sisters or Friends / Peers are Poor Responsible Rocking or Other Repetitive Movements Runs Away Sad, Unhappy Self-Harming Behavior (Biting, Hitting, Head-Banging, Scratching) Speech Difficulties Sexual Preoccupation Shy, Timid Stubborn Suicide Talk or Attempt Swearing, Blasphemes, Bathroom Language Temper Tantrums, Rages Thumb Sucking, Finger Sucking, Hair Chewing Tics -Involuntary Rapid Movements, Noises, Word Productions Teased, Picked On, Victimized, Bullied Truant, School Avoiding Underactive, Slow-Moving, Slow-Responding, Lethargic Uncoordinated, Accident-Prone Wetting or Soiling Bed Clothes Work Problems, Employment, Workaholism/Overworking, Can't Keep a Job
Who may We Thank for Referring You to TCC? (Name, Relationship, Phone #)
Please Type In Your Full Name to Electonically Sign
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