Adolescent/Child's Name
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First Name
Last Name
Gender
Date of Birth
*
MM
DD
YYYY
Age:
*
Grade Level:
*
Pre-K
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade
College
Email:
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Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Who (parent/legal guardian) will be accompanying the student for each session?
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First Name
Last Name
Gender
*
Relationship to Adolescent/Child:
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Mother/Legal Guardian Name:
First Name
Last Name
Age:
Preferred Phone #:
"By providing your phone number, you agree to receive text messages from Watershed Ministries. Message and data rates may apply. Message frequency varies."
(###)
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment status & description:
Marital Status:
Religious Affiliation/ Church:
Step-parent name:
First Name
Last Name
Father/ Legal Guardian Name:
First Name
Last Name
Age:
Preferred Phone #:
"By providing your phone number, you agree to receive text messages from Watershed Ministries. Message and data rates may apply. Message frequency varies."
(###)
###
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment status & description:
Religious Affiliation/ Church:
Marital Status:
Religious Affiliation/ Church:
Step-parent name:
First Name
Last Name
Religious Affiliation/ Church:
Describe, if applicable, custody agreement:
Requested copy of separation agreement for EMR:
Family Composition: Who currently resides in the same house as the child?
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Please include everyone including half or step siblings, house guest, and/or extended relatives.
Please note any other special family composition situations such as extended visitations with family or joint custody.
Describe Adolescent/Child's living arrangements:
Describe other significant supports:
Describe parenting style(s):
Describe current or past DSS-Child Protective Services and outcomes:
Describe Adolescent/Child’s spiritual/faith-based beliefs:
School Name:
Grade:
Teacher(s) Name:
Describe learning styles:
Describe student's attitude about school and any stressors:
List any learning struggles or diagnosed disabilities:
IEP or 504 Accommodations/AG Program:
List any extra curricular activities in/out of school and work:
List any current/prior suspension(s) or behavioral problems:
Describe Adolescent/Child’s friendships:
Describe any concerns related to bullying:
List hobbies and interests:
Amount of daily screen time (ie, Phone, Tablets, CPU, TV, Gaming, Other):
Social Media use & concerns (ie, Internet, texting, Instagram, Gaming, etc.):
List any boundaries/limitations for electronic devices access:
Has your child received any previous counseling?
If so, why?:
Please include outcome and diagnosis:
Counseling/ Therapy Names:
Pediatrician/Primary Care Provider:
Date of last exam:
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Rate your child's health:
Does your child have an addiction?
Has your child ever been arrested?
List any Medical or Psychiatric hospitalizations:
Describe any medical conditions related to counselee:
List current medications and prescribing physician:
Enuresis/Encopresis:
(bedwetting/soiling)
Describe Adolescent/Child's sleep cycle:
Describe Adolescent/Child's diet/appetite:
Allergies/Adverse Reactions:
Sexually active?
In case of an emergency, who should we notify?
Describe relevant history (prenatal care; full-term/preemie, complications, developmental milestone, etc.):
List any speech, occupational, physical therapies and outcomes:
List any mental health or learning diagnosis of siblings:
Adolescent/Child's Maternal family:
Adolescent/Child’s Paternal family:
Please describe event(s), treatment, and outcomes.
Include age of events
Adolescent/Child’s substance use/abuse:
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Yes
No
Unsure
Describe use history:
Describe:
Safety Plan:
Describe parental commitment to treatment, including any barriers:
Religious Background:
Does this Adolescent/Child believe in God?
Would you say they have a personal relationship with God?
How frequently do they read the Bible?
How often do they pray?
Church presently attending:
Church Name:
Pastor's Name:
Average times attended per month:
Do they enjoy attending church?
Please check anything that the child has gone through in the last 12 months:
What concerns has caused you to bring your child in for counseling at this time?
What has been done about your concerns up to this present time?
Has anyone in the family experienced similar problems?
What specifically do you expect your counselor to do to help you address your concerns?
What is your assessment of the child's personality?
Strengths/Weaknesses, etc.
How would your child describe the problem?
What is the current family situation?
How do the parents relate to each other?
What is the parents style of discipline?
What are your expectations for this child?
How is the child different from the other members of the family?
How does the child handle stress?
Is there any other information that you think your counselor should know?
Do you give permission for Watershed Ministries to contact you by Phone, Text and/or Email?
*
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Where did you hear about Watershed Ministries? Who referred you?