New Client Questionnaire (Child)

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Preferred Name

Date of Birth

Street Address

Street

City

State

State & Zip

Primary Phone Number

Primary Email Address

Gender at Birth

Male Female

ReWritten Counseling does not complete requests for disability as a part of our standard services.

I acknowledge and understand

Counselors reserve the right to temporally pause sessions with a client when an unpaid balance reaches $100. Once balance is paid in full sessions can resume.

I acknowledge and understand

Parent or Guardian Information

Add another parent or guardian

Can we send appointment reminders by text messaging?

Yes No

Medical History

Has the child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for the visit

Primary Care Physician

Date of last physical exam

Please list the medications the child is taking and for what conditions. Include the dosage and amounts.

Does the child have any allergies to medications?

Emergency Contact Information

Add another emergency contact

Preferred Appointment Type

In Person

Telehealth

Insurance Information

Add secondary insurance coverage

Current Symptoms

In your own words, describe the current problems as you see them:

How long has this been going on?

What does your child currently do too often, too much, or at the wrong times that gets him/her in trouble?

What does your child fail to do as often as you would like, as much as you would like, or when you would like?

What do you hope to gain from this evaluation and/or counseling?

If your child has had difficulties in the past, what are your child's strengths in coping or overcoming challenges?

What does your child enjoy or feel that they do well? Do they participate in any extracurricular activities (i.e. sports, hobbies, clubs, church group, etc.)?

What does your child do that you like? What does he/she do that other people like?

Please note any other symptoms, concerns, or experiences not noted above

Has your child seen a counselor, psychologist, psychiatrist or other mental health professional before? Has your child been hospitalized for psychiatric reasons?

Yes No

If so, please list name of therapist or hospital, reason for seeking help, and dates of treatment.

Developmental and Medical History

Did the child's mother have any problems during the pregnancy or at delivery?

Yes No

If so, please describe them

Family History

Who are other household members with your child?

Include names, ages, and relationship to child

Who are your child's significant others NOT living with your child?

Include names, ages, and relationship to child

Has anyone in the child's family received counseling services or treatment currently or in the past for a mental health or substance abuse disorder?

Yes No

If so, please provide details regarding diagnosis and family relationships

Educational History

Current School

Grade

Teacher's name

What does your child's teacher say about him/her?

Has your child ever repeated a grade?

Yes No

Has your child ever received special education services?

Yes No

Other History

Has your child ever experienced any type of abuse (physical, sexual, or verbal)?

Yes No

If so, please describe

Has your child every made statements of wanting to hurt him/herself or seriously hurt someone else? Has he/she purposely hurt him/herself or another?

Yes No

If so, please describe

Has your child ever experienced any serious emotional losses (such as a death of or physical separation from a parent or other caregiver)?

Yes No

If so, please describe

Please note another other things that are currently stressful to your child and his/her family that are not noted above.

Who can we thank for your referral?

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