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Adolescent Client FormLifebuilders Counseling2022-07-10T00:46:37+00:00

Please fill out the following form if you are an adolescent client.

Adolescent Client Form

Client First Name(Required)

First

Client Last Name(Required)

First

Sex(Required)

Male

Female

Email Address(Required)

Phone(Required)

Mother's Name(Required)

Father's Name(Required)

Do you have a counselor that you prefer? If so, whom?(Required)

Client's Mother

Give a description of your mother’s personality and her attitude towards you.(Required)

Are you able to confide in your mother?(Required)

Yes

No

Do you feel loved, respected and accepted by your mother?(Required)

Yes

No

Is there anything notable, unusual or stressful about your relationship with your mother?(Required)

Yes

No

If Yes, please explain:(Required)

Client's Father

Give a description of your father's personality and his attitude towards you.(Required)

Are you able to confide in your father?(Required)

Yes

No

Do you feel loved, respected and accepted by your father?(Required)

Yes

No

Is there anything notable, unusual or stressful about your relationship with your father?(Required)

Yes

No

If Yes, please explain:(Required)

Client's Family

Give an impression of your home atmosphere:(Required)

What family involvement would you like to see in counseling?(Required)

How often does the family spend time together and how is that time usually spent?(Required)

Medical History

On average how many hours do you sleep daily?(Required)

Do you have trouble falling asleep at night or waking in the middle of the night?(Required)

Yes

No

Describe your appetite (during the past week):(Required)

Poor

Average

Large

Comments on your eating habits/nutrition:(Required)

Do you use or have a problem with tobacco, alcohol, or other drugs?(Required)

Yes

No

If Yes, please describe:(Required)

Education & Social History

Do you have trouble keeping friends?(Required)

Yes

No

Have you had problems with being teased or bullied?(Required)

Yes

No

Do you prefer to be alone?(Required)

Yes

No

Do you have a close friend?(Required)

Yes

No

Are you as invited/included in activities (sleepovers, parties) as much as other teens?(Required)

Yes

No

Are you quite conscious of your appearance or weight?(Required)

Yes

No

Do you find it easier to be friends with members of the opposite sex than those of the same sex?(Required)

Yes

No

Who are the most important people in your life?(Required)

Describe any hobbies or interests:(Required)

List your main difficulties in school:(Required)

List your main difficulties at home:(Required)

Please describe how you express anger:(Required)

Please describe how you express anxiety:(Required)

List three of your strengths:(Required)

List three areas that need improvement:(Required)

Do you have a history or recent occurrence(s) of abuse?(Required)

Yes

No

If yes, what kind(s)?(Required)

Verbal/Emotional

Physical

Sexual

Please state when and describe:(Required)

Phone

This field is for validation purposes and should be left unchanged.

lifebuilders

In person and telehealth sessions offered.

306 West Sadie Street
Brandon, Florida 33510
cccbrandon@aol.com
Call us: 1-813-438-5949

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