Teen Intake Form

GENERAL
Name (required): Date of birth
Address:
City: State: ZIP:
Home phone: May I leave a message? YesNo
Work/Cell phone: May I leave a message? YesNo
Email: May I contact you via email? YesNo
School:
Emergency contact: Phone: Relationship:
Learning disabilities:
Nationality/religion (if relevant):
Who lives in your home with you? (kin, quality of relationship, names, ages):


TREATMENT INFORMATION
Reason for coming in for counseling/therapy at this time:

What you would like to be different in your life when you are done with therapy? What do you hope to achieve with therapy?

Please check any of the following major stressors in the past year or so that may pertain to you and/or your family:
Death of a Close FriendDeath of a Family Member
Major Illness in FamilyNew Addition to Family
Parents' Divorce or SeparationFamily FinancesAcademic Struggles
Peer or Social PressuresOther Personal Struggles

Your perception of current marital satisfaction of parents:


PERSONAL HISTORY
General health:
Physician’s name: Telephone:
Medications:
Reason for medication:
Have you ever been hospitalized for a physical illness? YesNo
Describe:

Previous therapy/counseling: YesNo
If yes, describe reason, duration and outcome:

What do you consider your strengths as a person?

What do you consider your areas of challenge as a person?

Have you ever considered or attempted suicide? YesNo
If yes, please explain:

Do you currently drink alcohol? YesNo
How much/how often:
Do you currently use recreational drugs? YesNo
How much/how often:
Do you feel you have a problem with alcohol or drugs? YesNo
Are you sexually active? If so, do you feel you understand how to keep yourself safe? Would you like to know more?

Have you ever been physically or sexually violated by a peer or adult in your life? If yes, did you share what happened with an adult? Outcome?

What are some activities you enjoy outside of class time:

Have you noticed a change in work habits, motivation, interest? Please explain:

Number of hours per a day on computer, ipad, itouch, etc.?:

Number of hours per a day texting:

How well do you sleep? How many hours do you get each night?

How much time do you spend alone? By choice or circumstance?

Is there anything else that you feel it would be important for me to know?

Please check any of the following struggles that pertain to you:
General AnxietyWorries about the FutureSelf-ControlSchool Stress
DepressionSuicidal ThoughtsDrug/Alcohol UseUnhappinessPast Trauma
Health ProblemsFears/PhobiasParental Marital Stress
InsomniaCutting/Self-MutilationEating Disorders
RelationshipsAngerReligious ConcernsThought Patterns

FAMILY INFORMATION
Parents and step-parents (indicate under “age” if deceased)
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation
First Name Age Education Marital Status Occupation

Siblings and step-siblings (indicate under “age” if deceased)
First Name Age Gender
First Name Age Gender
First Name Age Gender
First Name Age Gender

Get The Basics Right Stock http://www.abomarwan.com/articles/1488 Market Investing " The BasicsStock markets allow you to buy a small portion of a company (called a share). You’ll http://www.babies-cute.com/ get http://blog.mindmentor.org/?p=881 a proportional share of the revenue generated by the firm, and be able http://www.jomfruholmen.no/2015/09/cheap-jerseys-wholesale-jerseys-from-china-free-9zg057-wholesale-jerseys-from-china/ to vote in the company’s elections on choosing its board of corporate governance, selecting its Chief Executive Officer and Chief Financial http://www.volleyskills.com/?p=1647 Officer.A publicly traded company is one that http://www.boroughmarketbusiness.com/ has its shares of stock traded on a stock exchange, like the Dow Jones Industrial Average, or the New York Stock http://androidclubhouse.in/?p=592 Exchange. Publicly traded http://asaustin.org/ companies have significant burdens of public disclosure to live up to, mandated by the Securities and Exchange Commission (SEC). The SEC mandates that http://news.googlehubli.com/live/cheap-jerseys-cheap-nfl-jerseys-free-0aa327-wholesale-jerseys-from-china/ financial reports maintain http://10823.w23.wedos.ws/?p=89 a certain level of transparency, and appropriate disclaimers.Not all funds http://smartenupnas.com/ are publicly traded " for example, purchasing shares of Berkshire Hathaway, Warren Buffet’s holding company, can http://foxtaildevelopment.co.uk/cheap-jerseys-cheap-jerseys-china-free-shipping-291-wholesale-jerseys-from-china/ only be done by contacting the company directly.When investing in http://5online.tv/cheap-jerseys-mlb-jerseys-free-shipping-6ge03-wholesale-jerseys-from-china/ stocks, there are
platino Nike Free Run Donne Confort.,2014 Nike Free Run Gym Nero Rosso Uomini Commercio all’ingrosso Pri., http://10-5.jp/?p=1059 whose firm was among Visteon’s 10 biggest shareholders as of March,Nike Roshe Run Yeezy gris rosa claro de la Mujer Entrega Rpida y B., according to data compiled by Bloomberg. "Based on the sum of the parts,Nike Free Run 2 2,Nike Free Run 4.0 V2 Cool Grey reflectante Plata Negro Se Openning .,Nike http://newcameragear.com/ Roshe Run Fb Yeezy azules amarillas Mujeres Comercio Al Por Ma., it could be a reason they would want to sell. in New York. The company earned less than a penny in operating income for http://edinburghbooks.net/2015/09/cheap-jerseys-cheap-nfl-jerseys-free-9jx753-wholesale-jerseys-from-china/ each dollar of sales in the past 12 months,2014 cheap nfl jerseys Nike Free Run Gimnasio Blanco Azul Hombres Venta Worldwide Con.,Nike Free Run 5.0 V3 2012 Silver Mujeres Purple Ahorrar Hasta Un 79%, the lowest among auto parts makers http://www.interactivemagician.co.uk/ with more than $1 billion in value,Nike Free Run http://www.fondationberliet.org/?p=11565 3.0 V4 amarillas azules Mujeres Ahorra Hasta Un http://watchwrestling.tv/ 65% A., http://www.albertolongo.it/?p=12337 the data show. .," Colin Langan,2014 Nike Free Run Gimnasio Blanco Rosa Mujeres
City clerk gets copy of cookbook published Long before Rachael Ray, there was Ida Bailey Allen. Mrs. Woolworth Co., the famous five and dime wholesale oakleys chain that discount ray ban online opened its second store in Watertown. After hearing about Watertown link to the giant retailer, Illinois resident Sharon M. Rush fake cheap oakleys knew she had something that would be worth saving in the city historian vast collection of Woolworth related cheap oakleys material. The book, wholesale ray ban outlet called "The Service Cookbook Number One," belonged to her mother, Dorothy Gilbert, until she died about 10 years ago. Mrs. Rush then gave it to her mother in law, Devern Rush. Sharon Rush said she didn think much about the cookbook until her mother in law died earlier this year and she came across it while cleaning out her house. So she called the city clerk office a few weeks ago to see whether it would be a valuable addition to the fake oakleys store material it has. "Being over three quarters of a century old, I know it will be priceless in the right hands," she wrote in a Nov. 29 letter to City Clerk and
Community Justice Services Sheridan Community and Justice Services program prepares you for cheap fake oakleys a future working within the correctional field, often dealing with adult offenders or members of vulnerable sectors of society, like youth. The program combines a strong theoretical foundation in the social sciences, particularly psychology, fake oakleys Sunglasses criminal law and criminology, with an intensive hands wholesale ray ban on experiential focus. Proper use of static and dynamic security techniquesProfessors teaching your college classes are not only outstanding educators, but are also well experienced in the correctional field. You’ll learn through: Group activities including mock interviews, role playing and collaborative assignments Presentations by guest speakers from the field Field trips to facilities such as youth centres, jails and halfway houses Lectures by criminal justice program instructorsFollowing an individual interview to determine your specific career interests, you’ll undertake a field placement in a correctional setting such as cheap fake oakleys sales an
Be Sociable, Share!