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By signing the following document electronically, it is to be the legally binding equivalent of your individual handwritten signature.



Is there any required custody documentation?

Do you have the same contact information as the client?

Can we E-mail you?

How do you prefer to be contacted? (check one)

Can we text you on your cell phone?

Can we discuss your appointment times with your spouse/child?

Can we thank them for the referral?

Do you want faith/spiritual issues incorporated into the counseling process?

Are you currently employed?

Please rate the severity of your present concern: (check one)

Has your child received counseling, psychiatric or psychological treatment before?

Were the results positive?

Has your child been diagnosed or treated for any type of mental illness?

Has your child suffered any form of abuse?

Has your child ever attempted suicide?

Has your child ever tried self-mutilation/self-harm?

How would you rate your child's current physical health? (Check one)

Is your child currently experiencing any physical problems? (e.g. headaches, body aches, stomach problems,)

Is your child currently sexually active?

Marital Status

Are there difficulties within your marriage now?

If yes, do you think these difficulties are contributing to your concerns?

Has he/she changed schools recently?

Does your child get along with teachers & other students?

Have you or your child ever been convicted of anything other than a misdemeanor?

Have you or your child ever abused drugs?

Have you or your child ever abused alcohol?

Do you or your child drink alcohol?