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Child Background/History Form
Nicole Pray
2023-12-11T09:06:13+12:00
Child Information Form
Which team member are you here to see?
(Required)
Please select
Dr Nicole Pray
Who referred you?
Date
DD slash MM slash YYYY
Name of Child(ren)
(Required)
Name
Date of Birth/ Age
Ethnicity
Add
Remove
Address
Street Address
City
State / Province / Region
Postal Code
Child's School
Name of Parent(s)
Name
Date of Birth/ Age
Add
Remove
Address
Street Address
City
State / Province / Region
Postal Code
Email Address
(Required)
Home Phone
Mobile Phone
Employer
Work Phone
Please select where I can call you and leave messages
At Home
At Work
On your mobile
Marital Status
Please Select
Married
Separated
Divorced
Widowed
Living Together
Married how long?
Previously Married?
Yes
No
Siblings
Name
Date of Birth/Age
Step/Bio/Adopted
Add
Remove
Click on the plus + symbol to add multiple siblings
Medical History
Is your child currently experiencing physical problems or medical problems (e.g. headaches, body aches, stomach problems)?
Yes
No
Please list any learning disabilities:
Previous hospitalizations for medical reasons
Date
Reason
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Remove
Click on the plus + symbol to add multiple hospitalizations
If yes, please explain:
Counseling and Psychiatric History
Has your child had previous counselling?
Yes
No
If yes, when
If yes, for what reason?
Name and location of counselor:
For how long?
Has your child ever been diagnosed with or treated for any type of mental illness?
Yes
No
If yes, what?
Has anyone in your family been diagnosed with or treated for any type of mental illness?
Yes
No
If yes, what?
Medication Information
Medication(s)
Dosage
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Remove
Click on the plus + symbol to add multiple medications and dosages
Reasons for seeking help
What do you hope your child will gain from counseling?
What concerns have brought your child to counseling today?
Emergency Contact (Next of kin - other than spouse)
Name
Relationship
Home Phone
Work Phone
Address
Email
Would you like a copy of this form emailed to you?
Yes
Which email address should we send the form to?
