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Our Services
Our Counselors
Client Forms
Request Appointment
Juvenile New Client Intake Form
Please complete All Fields Of the form below.
Patient Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Age:
*
What is your gender?
*
Male
Female
Who's idea was it for you to come here? (Check all that apply)
*
Mine
Parents
Someone else
How do you feel about being here?
*
It's ok with me
I really dont care one way or the other
I don't want to be here
What event or problem has caused you to come for counseling?
*
What school do you go to?
*
What grade are you in? (If you are not in school what grade were you in last)
*
What activities are you involved in? (Like Sports, music, etc.)
*
What do you like most about school?
*
What do you like the least about school?
*
Besides school activities what do you do for fun?
*
How much time do you spend with other teenagers?
*
Are you happy with your relationships with other teenagers?
*
If not why?
Do you have someone that you can talk to about personal issues with and if so, who is that person?
*
Do you have a boyfriend/girlfriend? If so how long have you been dating?
*
If you are dating are you having any problems in that relationshhip?
Please explain:
*
What is your general opinion of adults? (Check all that apply)
*
Helpful
Smart/wise
Caring/loving
Don't care
Friendly
Can be trusted
Don't understand me
Can't be trusted
Too strict
Usually mean
Stupid
Too busy for me
Are you curently having any health problems? If so, please describe:
*
Are you having? (Check all that apply)
*
Frequent headaches
Trouble falling asleep
Feel tired most of the time
Problems with forgetting things
Recent weight change
Trouble staying asleep
Trouble concentrating
Sexual concerns
What medicines are you currently taking?
*
Do you have any allergies? If so what are they?
*
Have you ever been arrested or charges with a crime? If so please tell us details about the crime and tell me what punishment you got for committing the crime (Probation, fine, etc.)
*
Check the feelings that you have frequently:
*
Happy
Irritable
Confused
Hyped up
Worried
Stressed out
Sad
Nervous/anxious
Confident
Guilty/ashamed
Lonely
Tense
Angry
Bored
Shy
Depressed
Suicidal
Wothless
How often have you used the following substances? Cigarettes
*
Never
A couple of times
More than a couple of times
When was the last time you smoke a cigarette?
Alcohol
*
Never
A couple of times
More than a couple of times
When was the last time you used alcohol?
*
Marijuana
*
Never
A couple of times
More than a couple of times
When was the last time you used marijuanna?
*
Speed
*
Never
Acouple of times
More than a couple of times
When was the last time you used speed?
*
Cocaine
*
Never
A couple of times
More than a couple of times
When was the last time you used cocaine?
*
Text
Hallucinogens
*
Never
A couple of times
More than a couple of times
When was the last time you used hallucinogens?
*
Have you ever used any other substances? If so what substances?
*
If so how often?
*
Never
A couple of times
More than a couple of times
When was the last time you used these substances?
Please list the names of everyone in your immediate family and how they related to you. (Father, step-mother, brother, etc.) Are they living with you? Please describe your relationship with each one. (Getting along great, have lots of conflict, etc.)
*
If there was anything you could change about your family what would it be?
*
Have you ever had a really bad experience in your life and if so, please explain?
*
Is there anything else that I need to know about you or that you would like to talk about?
*
Name of minor:
*
Age:
*
Date of birth
*
MM
DD
YYYY
Consent for parent or legal gaurdian. I am the legal custodian of the above-named minor and: (Check one)
*
I have full legal authority to consent to treatment of the monor without obtaining consent or approval of another person.
I have joint custody of the minir pursuant to a decree that requires both my consent and the consent of another person.
I hereby authorize bridge of hope to provide counseling to the minor in connection with mental health and/or other personal problems. Legal custodian needed to type there name here as signature:
*
Date of signature
*
MM
DD
YYYY
I understand that my records are protected by civil law in the state of Texas and all communications with a mental health professional are considered privileged. Certain records are also protected by the Federal Privacy Act of 1974 and HIPPA. I understand tha I may revoke this consent at any time expect to the extent that action has already been taken. Type the name of client below:
*
Client Date of Birth
*
MM
DD
YYYY
I authorize the following person to share my information:
First Name
Last Name
Address of person sharing information:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Fax Number:
(###)
###
####
I authorize the above person to exchange information with this person below:
First Name
Last Name
Address of person to exchange information with:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Fax number of person to exchange information with:
(###)
###
####
This consent is limited to the following type of information:
This information is share for the purpose of:
Signature of client by typing below:
Signature of parent/gaurdian if client is a minor is typed below:
Date of signature
MM
DD
YYYY
Thank you!
