Can you Please Share (FaceBook, Twitter, SnapChat, Instagram, etc) that you use
What activities do you enjoy and feel you are successful when you try?
Who are some of the influential and supportive people, activities (e.g. walking) or beliefs (e.g. religion) in your life?
Briefly describe the challenges that you may have?
What is your treatment goal?
what did you find most helpful in therapy/Psychiatry?
how much do you drink per time?
how much do you smoke/chew/Vap?
what drugs do you use
where did you go? was it Inpatient or outpatient
Please list any legal issues that are affecting you or your family at present, or have had a significant effect upon you in the past.
If your parents are divorced, whom do you primarily live with?
4. How often do you see each parent? Mom_________% Dad ___________%.
Please describe as much as you feel comfortable.
Please describe.
Please describe
Please describe
Please describe
Please describe
For what reason did your son or daughter go to Therapy before ?
Approximate Dates of Therapy,What did you find most helpful and least helpful in therapy?
Please describe
who did they see? , and was it helpful?
Name of medication, Dates taken and Was it helpful?
Date of Hospitalization, Reason of Hospitalization
please explain your concern
please explain your concern
Please list any legal issues that are affecting you or your family, son or daughter, at present, or have had a significant effect upon you or your son or daughter in the past.
Please describe
Please describe as much as you feel comfortable.
Please describe as much as you feel comfortable.
Please explain.
Length of marriage/relationship?
how old was your child at time of divorce?
How much time does your child spend with each parent? Mother_____%, Father _____%
Please explain
What activities do you feel your son or daughter is successful when they try?
What personal qualities would you say your son or daughter has?
Who are some of the influential and supportive people, activities (e.g. walking) or beliefs (e.g. religion) in your son or daughter’s life? (Please describe)
Is there anything else you would like to share?