| Client name: |
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| Address: |
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| E-mail: |
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| Home phone: |
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| Work phone: |
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| Cell phone: |
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| Best number & time to call: |
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| Marital status: |
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| Ethnicity: |
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| Ethinicity (if selected other): |
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| Employer: |
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| Employer address (street): |
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| Employer address (city): |
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| Employer address (state): |
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| Employer address (zip code): |
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| Do you have a lawyer? |
No
Yes
If yes, please provide lawyer name and phone number below:
Lawyer Name:
Lawyer Phone Number:
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| What is your annual salary: |
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| How much child support do you pay? |
Monthly:
for how many children?
since which year?
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In your own words, what do you need our help with at this time?
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Your family history (dates of marriage, divorce, etc.):
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Other parent's name: |
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| Phone number: |
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| Marital status: |
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| Address: |
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Your current legal custody agreement:
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Your current actual custody situation:
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Child or children's details:
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| Child (1) name: |
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| Child (1) date of birth: |
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| Child (1) age: |
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| Child (1) sex: |
Male
Female |
| Child (2) name: |
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| Child (2) date of birth: |
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| Child (2) age: |
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| Child (2) sex: |
Male
Female |
| Child (3) name: |
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| Child (3) date of birth: |
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| Child (3) age: |
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| Child (3) sex: |
Male
Female |
| Where do you currently live? |
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| Do you think the other parent will consent to assessment? |
Yes
No |
| Who, if anybody, referred you to our practice? |
Name:
Phone number:
Do you have permission to thank the person who referred you?
Yes
No
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| Are you currently receiving psychiatric services, professional counseling or therapy elsewhere? |
Yes
No
If yes, therapist name and phone number:
Name:
Phone number:
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| Have you had previous psychological counseling? |
Yes
No |
Child's History
Describe academic functioning (learning problems or highlights):
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Describe any major medical/physical problems:
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List known allergies:
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List hobbies or sports your child is interested or involved in:
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Any additional information:
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Services |
| What type of services are you seeking? Check all that apply |
Unsure. Would like evaluation and recommendations for services.
Individual Psychotherapy
Family Therapy
Visitation Supervision
Group Therapy
Forensic Services
Family System Analysis
Neuropsychological Evaluation
Psychological Evaluation
Mediation
Risk and Resiliency Evaluation
Consultation
Educational Evaluation
Developmental Evaluation
Expert Witness Services
Lawyer Referral Services
Other, please specify:
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History of court appearances, current charges, motions, etc.:
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| Issue # 1 |
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| Issue # 1 date |
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| Issue # 1 court |
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| Issue # 1 Disposition of case |
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| Issue # 2 |
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| Issue # 2 date |
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| Issue # 2 court |
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| Issue # 2 Disposition of case |
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| Issue # 3 |
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| Issue # 3 date |
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| Issue # 3 court |
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| Issue # 3 Disposition of case |
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| Issue # 4 |
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| Issue # 4 date |
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| Issue # 4 court |
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| Issue # 4 Disposition of case |
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Any additional information that you would like to give us to better help us evaluate your situation:
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