| Today's Date: |
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| Clent's Name: |
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| Client's Date of Birth: |
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| Parent(s)/Guardian(s): |
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| Client's Address: |
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| Members of Household: |
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| DCF Worker: |
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| Pediatrician or Primary Care Physician: |
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| Psychiatrist: |
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| Reason for Seeking Therapy (Be Specific): |
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| Past Psychiatric History (Treatment Dates and Facilities): |
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| Past Trauma or Abuse: |
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| Significant Losses: |
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| Relationships with Peers and Family (Strained or Stable): |
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| Substance Abuse or Dependence (Substances of Choice and Duration of Use): |
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| Current Psychiatric Diagnosis (Depression, Anxiety, PTSD, Adjustment Disorder...): |
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| Past Psychiatric Diagnosis (Depression, Anxiety, PTSD, Adjustment Disorder...): |
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| Current Thoughts of Suicide: |
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| Past Thoughts of Suicide: |
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| Suicidal Attempt(s) (Date and Circumstances): |
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| Experience with Self-Injury (Cutting, Scratching, Burning...): |
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| Disordered Eating (Bulimia w/vomitting or excessive exercise; Anorexia): |
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| Sleep Problems (Trouble falling asleep, multiple wake-ups, sleeping too much): |
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| Problems with Anger and Rage (Threat to others or self, destroying property, verbally abusive...): |
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| Current Major Stress in Life: |
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| Current School and Grade Level: |
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| Special Education Plan or IEP: |
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| Place of Employment: |
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| Type of Insurance: |
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| Subscriber's Name and Date of Birth: |
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| Current Psychiatric Medications: |
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| Past Psychiatric Medications: |
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| Family History of Substance Abuse: |
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| Family History of Mental Health Problems: |
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