Personal Data Inventory for Minors Age 12 and Under

Personal Data Inventory for Minors Age 12 and Under
Today's Date

Month Day Year
Child's Name

First Name Last Name
Age
Date of Birth

Month Day Year
Mom's Name:

First Name Last Name
Dad's Name:

First Name Last Name
Stepmom:

First Name Last Name
Stepdad:

First Name Last Name
Siblings Names and Ages:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
E-mail
Parent's Occupation(s)
Do you agree to wait outside of our office during the counseling session, in plain view of our front windows?
Are you and the child's other parent currently married and living together? If not, what is your situation? Explain:
Who is your child's physician?
Is your child in good health? If not, explain:
What medications is your child taking?
Has your child received any other counseling? Where?
Is your child currently seeing another counselor? Who?
What grade is your child in, and at what school?
How is your child doing in school in general?
Does your child have learning challenges? Explain:
What church do you and your child attend? How often?
What church activities is your child involved in?
Please describe what brings you for counseling at this time:
What are your goals and hopes for this counseling?
How have you tried to help your child with the current struggles?
Please briefly describe your child (shy, outgoing, sensitive, kind, a bully, anxious, unhappy, obedient, etc...use whatever words fit your description):
Is there a history of mental illness is your family? Explain:
What are some of your child's interests?
Is there anything else you think we should know? Explain:
Should be Empty: