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 1 Adopted – child resides with legally adoptive parents Foster Care – child resides in foster care or group home placement Page 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 2 Educational/School Work Unhappy most of the time Page 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: 3 Signature of Parent/Guardian of Minor Page 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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