Download File - U'Lawnda Lewis_ LPC - Welcome

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					                                                                                                                U’Lawnda Lewis, LPC
                                                                                                                    Client Information Form
                                                                                                                                     (Minor)
       General Information
               Name of Child: ___________________________________________________________                    Date: ______________________

               Social Security:______________________________            Age:__________      Date of Birth:_____________________________

               Street Address:____________________________________________________                  Apt. No.:__________________________

               City:___________________       State:_________        Zip Code:_____________

               Name of Parent/Guardian: __________________________________________ Relationship to Child:____________________

               Street Address (if different):__________________________________________________________ Apt. No.:_____________

               City:___________________       State:_________        Zip Code:_____________



       Contact Information:                                                    Preferred                  May I leave a message?
               Cell phone: ______________________________                                                     Yes        No
               Home phone: ____________________________                                                       Yes       No
               Work phone: _____________________________                                                      Yes       No
               Email: ___________________________________                                                    Yes        No



       Emergency Contact
               Name:______________________________________ Relationship:_______________________________

               Home Phone: (________)_________________________ Mobile Phone: (________)_________________



       Child’s Current Living Situation
       Family structure:

                Intact – child lives with both biological parents      Child lives with separated or divorced biological parent(s)

                Child splits time between both biological parents

                Is there a court order regarding custody?              Yes              No

       Other Family Structure:

                Extended family – child resides with other family member, but is not legally placed or adopted
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                Adopted – child resides with legally adoptive parents  Foster Care – child resides in foster care or group home placement
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         PLEASE NOTE: IF YOU MISS AN APPOINTMENT OR DO NOT CANCEL 24 HRS IN ADVANCE, YOU WILL BE ASSESSED A $30
                                               MISSED APPOINTMENT FEE.
       Billing Information
                Party Responsible For Payment: ______________________________________ Relation To Client: ____________________

       Insurance Information
                Insurance Company: ___________________________________________________________________________________

                Policy Holder’s Name: _________________________________________________________________________________

                ID Number: _________________________________ Employer: _______________________________________________

                Group Number/Name: _______________________________________



       Other Children
                List your Children (Living or Deceased):          (please use separate sheet for additional children)

                              Name                        Sex      Current Age    Relationship to     Living            Describe Him/Her
                                                                    or Year of   You (e.g. Natural,    with
                                                                     Death?       Adopted, Step)      You?




       Academic/School Information
                Name of School: ___________________________________________________________ Grade: ____________________

                Has Your Child Ever Repeated A Grade? _______________ If So, Which Grade: __________________________________

                Describe Any Learning Difficulties: _______________________________________________________________________




       Presenting Issues
       In the following list, place a check mark next to each item which identifies an area of concern to you. Place two checks by those items
       which are most important/higher concern.

                          Anger/Temper                                    Sexual Concerns

                          Depression                                      Thoughts of Suicide
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                          Educational/School Work                         Unhappy most of the time
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                          Family Problems/Fighting w/Siblings             Use of Alcohol
         PLEASE NOTE: IF YOU MISS AN APPOINTMENT OR DO NOT CANCEL 24 HRS IN ADVANCE, YOU WILL BE ASSESSED A $30
                                               MISSED APPOINTMENT FEE.
                           Fearlfulness/Phobias                          Use of Drugs

                           Insecure/Timid/Lack of Self Confidence        Worry

                           Conflict w/Parent(s)/Divorce/Separation       Physical Problems

                           Problems w/accepting discipline               Traumatic Stress

                           Problems in relationships w/other children    Stress


                          Other (Specify) ________________________________________________________________________________

       ___________________________________________________________________________________________________________



       Authorization/Consent to Treatment A Minor
       Are you legal parent or custodian to above-named child?                         Yes          No

       I hereby swear that I have legal right to obtain treatment for the above-named child?              Yes          No

       In instances of divorce, it is essential that the legal custodian of the child grant permission for the services. If you are a divorced parent, a
       stepparent, a grandparent, a guardian, or other, you may be asked to provide a copy of the court order which names you the legal
       custodian of the above children.

       Are you willing to do so?            Yes                No

       If the answer to any of the above questions is “No,” counseling services cannot be provide to the above-named child(ren) until a copy of
       the court order which names you the legal custodian is provided to the office.

       I, _______________________________________________________________________________, consent to U’Lawnda Lewis, LPC,
       in providing counseling services to the child named above. I acknowledge that both natural parents, even though divorced may have a
       right to obtain from U’Lawnda Lewis, LPC, information regarding the nature and course of treatment of the child(ren).

               Georgia State Law mandates the reporting of certain types of child abuse, including physical abuse, sexual abuse, unlawful
                sexual intercourse, neglect, emotional and psychological abuse. All actual or suspected acts of child abuse will need to be
                reported to the appropriate agency.
               This treatment may also include referral to other appropriate State and County agencies for further counseling.


                I declare that I am the custodial parent or legal guardian of the child described in this document and that I have the legal
                authority to bring him or her for treatment.

                I authorize treatment to be administered U’Lawnda Lewis, LPC.

                                                                                       Date:
                Signature of Parent/Guardian of Minor

                                                                                       Date:
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                Signature of Parent/Guardian of Minor
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          PLEASE NOTE: IF YOU MISS AN APPOINTMENT OR DO NOT CANCEL 24 HRS IN ADVANCE, YOU WILL BE ASSESSED A $30
                                                MISSED APPOINTMENT FEE.

				
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posted:1/14/2011
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