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Student/Teenager/Child Information Form
Name of Person Completing this form
Relationship to Student/Teenager
Your E-Mail
Your phone number
Parent Information
Parent(s) name(s)
Address(es)
Phone(s) (work, home, cell, pagers, how and when to best to contact)
Parent(s) employment (employer, type of work, days, hours, availability to speak)
How and when parents can be reached (how, day, night, emergency, messages)
Martial history (date of marriage, divorces, current marital status, on-going or recurrent problems)
Custodial Parent(s)
Address
Legal Gaurdian(s)
How and when Gaurdian(s) can be reached (how, day, night, emergency, messages)
Child's Information
Child's Name
Date of birth
Age
Weight
Height
Color eyes
Color hair
Adoption history (if adopted)
Brothers and Sisters (name, age, by marriage or biological relationship)
Grade in school
School history (drop out, expulsions, suspensions, held back, when, reasons)
Most recent physical (when, purpose, what was done, findings)
Medication allergies (drug name, reaction, treatment)
Current medications (drug name, when, dosage, purpose, name of prescribing physician)
Past medications (when, drug name, purpose, effectiveness, problems)
Current medical problems and treatment (allergies, skin, infections, injury, etc..)
Previous hospitalizations or surgery (when, what for, treatment, how long)
History of major injury or accident (when, what happened, treatment, lasting effects)
Birth history (trauma, complications, problems)
Criminal history (when, arrests, charges, detention, court appearance, tickets, fines)
Employment history (when, employer, type of work, problems, successes)
Alcohol, chemical and other drug use (when, used what, how long)
Traumatic life experiences (physical, psychological, when, what happened, treatment, lasting impacts)
Therapy or counseling history (when, name of person, title, diagnosis, treatment method, length of treatment, outcome)
Recent or unusual behavior that worries you.
History of destructive, violent, self-harming or suicidal behavior (when, what did your child do, your response, response by others, treatment if any)
Psychiatric hospitalization history (when, where, what for, how long, treatment, diagnosis)
Residential treatment history (when, what for, voluntary or mandatory education, treatment, how long, outcome)
Special program history (when, what for, voluntary or mandatory education or treatment, how long, outcome)
Special education plan (when, what was the plan, outcome)
Family History
Family issues, problems, conflicts, current or past that affect the family and child
Family history of psychiatric problems including relatives (who, relationship, diagnosis or disorder, treatment, medications, outcome)
Deaths in the family, suicide or accidental loss of life (when, who, relationship, how, impact on family and child)
Family history of alcohol, chemical or drug use (who, when, what, how long, treatment, outcome)
Family health (who, medical problems or conditions, when, how long)
Legal problems (what, when, how long, outcome or current status)
Custody, visitation or child support issues
Child's Medical History
Does your child have a potential problem or has your child ever been treated by a physician for any of the following medical problems.
Have your child ever been treated by a physician for any of the following medical problems.
Please describe the above problems you checked in more detail including current or past treatment and whether or not the problem is currently in remission, managed or under control. You may use as much space as necessary.
Please check those items that describe your child's alcohol or other drug use.
AlcoholCoffeeOther drinks that contain caffeineTobacco smoking productsTobacco chewing productsMarijuanaMethamphetaminesLSDCrack cocaineHeroine
Other
Child's Interests and Strengths
Please describe your child's hobbies, interest and talents
Please describe your child's education or career interests
Please describe your child's strength, abilities and positive qualities.