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Adolescent Client Form
Lifebuilders Counseling
2022-07-10T00:46:37+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)
Add
Remove
List your main difficulties at home:
(Required)
Add
Remove
Please describe how you express anger:
(Required)
Please describe how you express anxiety:
(Required)
List three of your strengths:
(Required)
Add
Remove
List three areas that need improvement:
(Required)
Add
Remove
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)
Email
This field is for validation purposes and should be left unchanged.
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