Client Information - Adolescent

Client Information: Adolescent

Please complete and submit this form at least one day before our first session. Your information will be encrypted and accessible only by me. Thank you.
Name*

First NameLast Name
Age*
Birthdate*

MonthDayYear
Date
E-mail*
example@example.com
Cell Phone *
Format: (000) 000-0000.
What activities do you enjoy and feel successful at?*
Please describe the influential and supportive people, beliefs, or activities in your life.*
Please describe the problem for which you are seeking counseling.*
What would you like to see happen as a result of counseling?*
Have you seen a mental health professional before? *

YesNo
What did you find MOST helpful in therapy? *
What did you find LEAST helpful in therapy? *
Please check all items that have been areas of concern for you in the last 6 months.

Aggression or angerAnxiety or worryCraving alcohol or other drugsFeeling down, depressed, or hopelessFood issues: overeating, reduced appetite, anorexia, binge eating, or purgingFeeling bad about yourself, feeling you are a failure, or feeling you have let yourself or your family downFeeling tired or having little energyHaving little interest or pleasure in doing thingsIrritable moodMood swingsPanic attacksPhysical health or chronic pain problemsPoor impulse controlSleeping too much, less need for sleep, or trouble falling or staying asleepTrouble concentrating on things such as reading or watching televisionEmotional or verbal abusePhysical or sexual abuseThoughts of harming yourself or others
Have you ever thought about or attempted suicide?*

YesNo
Please describe when this happened and what was going on in your life.*
Do you use alcohol or recreational drugs?*

YesNo
For each, please describe the type of alcohol or drug, how much you have, and how often.*
Please check any of the following that describe your experiences with alcohol or other drugs.*

I feel I have a problem with alcohol or other drugs.Others feel I have a problem with alcohol or other drugs.My drinking/drug use has caused problems in my family or relationships.I have been in treatment for substance use.A family member has been in treatment for substance use.None of the above
Please describe your parents' relationship. Are they married, divorced, etc.? How do/did they get along? *
Please describe your current living situation. Who else lives in your home? How often do you see each parent?*
Have you experienced any abuse (physical, verbal, emotional, or sexual) in your home or outside your home?*

YesNo
Do you have any siblings?*

YesNo
For each sibling, please list name, age, and how you get along.*
How do you get along with your parents? *
Please check any concerns that YOUR FAMILY is currently experiencing.*

ArguingFeeling distantJob problemsLoss of funAlcohol or drug useAbuse or physical fightsLack of honestyNeglectDivorce/separationNew family memberFinancial problemsDeath of a family memberNone of the aboveOther
How do you consider yourself socially?*

OutgoingShyDepends on the situationOther
Are you happy with the amount of friends you have?*
Are your parents happy with your friends?*
Have you ever been bullied?*
Who among your family, friends, and others are part of your emotional support system?*
Are involved in any organized social activities ( e.g. sports, scouts, music)?*
Do you like school?*
Are you happy with how you are doing at school? *
What do you consider to be your strengths?*
Is there anything else you would like me to know before we meet?
Electronic Communication: I do not conduct therapy via email or text message. Emails and text messages are neither secure nor confidential. Also, electronic communications are stored in cyberspace and authorities can access them under some circumstances. If you indicate your permission below, I may use email or text to handle scheduling and similar topics, and to respond to emails and texts that you send me. You agree that if you send me an email or text and request a response via electronic communication, you are willing to accept the above-stated risks.*

I consent to receive text messages and emails from Betsy Walli Sadur at the number and address given above.I do not consent to receive text messages or emails from Betsy Walli Sadur.Other
Signature
When you click the box below, your answers will be submitted and you'll see a message confirming that your submission was received. Thank you for providing this information in preparation for our first session. I look forward to working with you!

Please let me know if you would like a copy of your answers.
Warmly,

Betsy Walli Sadur
(310) 504-1893

ICEEFT-Certified EFT Therapist and Supervisor-in-Training
Certified Discernment Counselor
Board Member, Orange County Community for EFT
Licensed Marriage & Family Therapist #85860
PhD Linguistics, MS Marriage and Family Therapy

Online therapy in California and Florida

betsy@occounseling.net
www.occounseling.net
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Client Information: Adolescent