Child & Adolescent Client Information Questionnaire

Your cooperatiion in completeing this questionnaire will be helpful in planning our services for you and your child/adolescent. Please anawer each item carefully or ask for clarification if you do not understand an item.

Name: _______________________________________________ Today's date: _______________

Address: _____________________________________________ Telephone: _________________

D.O.B. : _______________ Age: __________ School: _________________________ Grade: ______

Briefy describe your concerns for seeking help: _____________________________________________

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Who suggested you contact us? _________________________________________________________

When was the last time your child was examined by a physician? _________________________________

List any health problems for which your child historically/currently receives treatment: ________________

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Please list any medications that are PRESENTLY used: ________________________________________

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Has your child ever received psychiatric help or psychological counseling of kind historically? _____________

If so, explain: _____________________________________________________________________

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