Teen SessionQuick In-take Form Thank you for taking the time to fill out this form. It is very important information that helps to inform our session and time together. Teen Information First Name Last Name Phone (###) ### #### Email * Birthday Age * What is your concern for child? * What is your child experiencing? What symptoms is your child experiencing? (Examples: Anxiety, social anxiety, insecurity, trouble at school, lack of motivation, stress, nervousness, fears, trouble sleeping) Do you know what could be causing your child to feel like this? Does your child take any medications? if so, please list Is your child currently receiving any support for this or other symptoms? Yes No Have they received support for this or other symptoms in the past? yes no If you answered yes to any of the two questions above, what support did they receive ? What has worked for your child currently or in the past? What are you and/or your spouse feeling about what your child is experiencing? What support do you need? Describe what the environment at home is like. Anything else you want to share or express? Parent Information (or Caretaker) First Name Last Name Parent's Phone Number (or Caretaker) (###) ### #### Parent's Email (or Care Taker) What is your relationship to the child? Mother Father Caretaker Silbing Relative Other Other Parent's Full Name and Phone Emergency contact name and number Thank you for sharing this with me. I look forward to meeting you. Michelle Instagram #teenworkshop #teenworkshop #teenworkshop
