Parent Form for Child/Adolescent Client

Please fill out the following form if you are a parent of a child/adolescent client.

Parent Form for Child/Adolescent Client

Client Name (Child)(Required)

First MI Last

Today's Date(Required)

Month

Day

Year

Child's Date of Birth(Required)

Month

Day

Year

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Mothers First Name(Required)

First

Mothers Last Name(Required)

Last

Mother's DOB(Required)

Month

Day

Year

Email Address (Mother)(Required)

Home Phone (Mother)(Required)

Cell Phone (Mother)(Required)

Parent's Name (Father)(Required)

First Last

Father's DOB(Required)

Month

Day

Year

Email Address (Father)(Required)

Home Phone (Father)(Required)

Cell Phone (Father)(Required)

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

Insurance

Insured Social Security(Required)

Insurance Co.(Required)

Insured Name(Required)

Insured ID(Required)

Treatment Concerns and Goals

Primary reason(s) for seeking services:(Required)

Do you feel that your child’s problems are affecting other members in the family?(Required)

Yes

If yes, in what ways?(Required)

Have there been any other significant changes or events in your child’s life? (family, moving, fire, etc.)(Required)

Yes

If Yes, describe:(Required)

Is there a history or recent occurrence(s) of abuse to the child/adolescent?(Required)

Yes

If yes what kind(s)?(Required)

Verbal/Emotional

Physical

Sexual

Please state when and describe:(Required)

Family History

Were the child’s parents ever married?(Required)

Yes

Divorced or separated?(Required)

Yes

If so, who has legal custody?(Required)

Medical History

Age for following developments (fill in where applicable):

Began puberty:

Began Menstruation:

Began Voice Change:

Child’s current height:(Required)

Child’s current weight:(Required)

Describe his/her appetite (during the past week):(Required)

Poor

Average

Large

Any emotional/physical problems?

Indicate any medications your child is currently taking. (Include prescribed and over-the counter medications, dosages, and the reason for taking.)

On average how many hours of sleep does your child/adolescent get?(Required)

Does he/she have trouble falling asleep at night or waking in the middle of the night?(Required)

Yes

Training and Discipline

How is the child disciplined by parent(s)?(Required)

For what reasons is the child typically disciplined by the parent(s)?(Required)

Do the parents agree on how and when to discipline?(Required)

Education

Current school:(Required)

Grade:(Required)

Teacher:(Required)

In special education?(Required)

Yes

If Yes, describe:(Required)

In gifted program?(Required)

Yes

If Yes, describe:(Required)

Has child ever been held back in school?(Required)

Yes

If Yes, describe:(Required)

Performance in School (Parent’s Opinion):(Required)

Satisfactory

Underachiever

Overachiever

Other

Social History

Child’s Peer Relationships:(Required)

Spontaneous

Follower

Leader

Difficulty making friends

Makes friends easily

Long-time friends

Other

Please describe:(Required)

Does your child show problems in any of the following social areas?

Communicating Effectively(Required)

Yes

Taking Guidance or Constructive Criticism(Required)

Yes

Being Aggressive(Required)

Yes

Unwillingness to Cooperate/Share(Required)

Yes

Willingness to Ask for Help(Required)

Yes

Problem with Authority Figures(Required)

Yes

What does the child/adolescent typically do with unstructured time?(Required)

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

Legal Issues

Are there any current legal issues that may be related as to why the client is in counseling, if so what is the issue?(Required)

Has your child/adolescent been mandated by a court or probation office to seek counseling?(Required)

Yes

Will a report be needed from your counselor?(Required)

Yes

Is there an expectation at this time that the counselor appears in court as a witness?(Required)

Yes

*Please note there will be additional costs involved for any reports or appearances made in court.

Consent to Treatment

This form is to document that I give my permission and consent to the Christian Counseling Center to provide counseling.

While I expect benefits from this treatment, I fully understand that because of factors beyond our control or other factors, such benefits and particular outcomes cannot be guaranteed. I understand that because of the counseling or therapy, I/he/she/we may experience emotional strains, feel worse during treatment, and make life changes which could be distressing.

I understand that this therapist is not providing an emergency service and I have been informed of whom to call upon in an emergency or during weekend and evening hours. I understand the counselor is a consultant and a professional resource only, whose intervention may be freely accepted or rejected by the client, therefore, decisions made during and after counseling are the responsibility of the client. I understand that regular attendance will produce the maximum benefits but that I am/are free to discontinue treatment at any time. I understand that the client is free to terminate services at any time.

I understand that conversations with the therapist will be confidential except as allowed by the Privacy Policy of the Christian Counseling Center. However, I understand there are limits to confidentiality based on payment methods, wireless and electronic communication that I elect to utilize. I further understand that Florida law requires any therapist who has reasonable cause to suspect child or elder abuse, neglect and abandonment/exploitation to report such knowledge to the appropriate authorities. I also understand that Florida law allows the confidentiality between the therapist and client to be waived when there is a clear and immediate probability of physical harm to the client, to other individuals, or to society and the therapist communicates the information only to the potential victim, appropriate family members, law enforcement or other appropriate authorities.

I understand that I am financially responsible for this treatment and for any portion of the fees not reimbursed or covered by third parties. I also understand that I am expected to pay for the counseling fees at the time of the visit and any arrangement for payments by third parties will be made before the counseling session. I understand that receipts will be provided for at each request.

Cancellation of Appointments
To avoid paying for cancelled appointments, the undersigned agrees to call CCC 24 hours before the date of the appointment. CCC offers the undersigned the option of having a telephone session to avoid having to pay a broken fee. The fee for a broken appointment is the full session rate unless your specific counselor has their own separate broken fee arrangement. After three or more cancellations my counselor has the right to cancel any appointments that may be scheduled out. CCC will notify the client that the appointments will be taken off of the schedule.

No show/ No call will result in an automatic full fee charge for the missed appointment. I understand that my counselor has final say in if a broken fee will still be applied or not.

Social Media Consent Form
Christian Counseling Center cannot guarantee confidentiality when it comes to using social media to connect with your counselor or staff of the Christian Counseling Center. This includes any social media online such as Facebook, twitter, etc.., email, skype, texting, or phone sessions. Any electronic communication cannot guarantee security and\or confidentiality.

When emailing a counselor please send the email to the Christian Counseling Center and not to your counselor’s personal email. Please use cccbrandon@aol.com if you wish to send something to your counselor. One of the staff members will then either forward the email to the counselor or print it out for the counselor to view. Please use email only for non-urgent situations. If you do not receive a timely reply, please call the Christian Counseling Center.

Phone

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