Staying Out Of The Middle – Building Blocks Counseling

Phone

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

Name*

First Last

Child lives with*

If parents are divorced, who has legal custody of child?*

Address*

Street Address Address Line 2 City State ZIP Code

Date of birth*

Age*

Sex*

Gender Identity*

Place of Birth*

City State

Was child adopted?*

Yes
No

At what age?*

Parental Information

Parent's Name*

First Last

Email*

Phone*

Date of birth*

Age*

Sex*

Gender Identity*

Employer*

Job Title*

Last grade completed in school*

Church affiliation*

May I send a thank you note to the person who referred you?

Yes
No

Parent Relationship*

Number of years married*

Number of years separated*

Number of years divorced*

Co-parental Information

Parent's Name*

First Last

Date of birth*

Age*

Address*

Street Address Address Line 2 City State ZIP Code

Phone (home)*

Phone (work)*

Phone (cell)*

Employer*

Job Title*

Last grade completed*

Legal Questions

Who has LEGAL custody of the child?*

If parents have joint custody, who has the final medical tie-breaker?*

If parents are divorced, our office needs a copy of the most recent court order showing primary custody or tiebreaker, or the consent of both parents.

Divorce, Separation, and Custody Agreements

Building Blocks Family Counseling will not be party to custodial, separation, or financial disputes relating to individuals with regard to minor children to whom services are provided. The individual who requests the counseling services and signs the financial agreement is responsible for any balance due. All co-pays, co-insurance, and deductible, if applicable, will be collected at the time services are rendered from the individual requesting the counseling services for the minor child/children. We expect consent from both parents for therapy services. The therapist will discuss the minor’s therapeutic information with the accompanied parent with the time of the visit. Building Blocks Family Counseling will provide a copy of any records requested, all though we reserve the right to charge a fee. Both parents have access to the minor child’s records, unless there is a court order that specifically mandates only one of the parents has the right to authorize treatment and release of the minor’s records.

Child's Background

How many siblings?

Name*

Age*

Relation*

Lives with?*

Name*

Age*

Relation*

Lives with?*

Name*

Age*

Relation*

Lives with?*

Name*

Age*

Relation*

Lives with?*

Name*

Age*

Relation*

Lives with?*

Name*

Age*

Relation*

Lives with?*

Any other people living at home?*

Are you or have you been involved with the Department of Family and Children Services (DFCS)?*

Please specify

Treatment/Medical History*

Please list any past treatment for psychological, psychiatric, medical, or counseling services the child has received. list all major illnesses, injuries, accidents, hospitalizations, allergies, or medical conditions.

Medications*

Chief concern*

Please describe the main difficulty that has brought you here

Please indicate any issues or concerns with the following*

Child's current school and grade*

Is your child currently receiving special education services? If yes, in what area?*

Child’s current hobbies, extracurricular activites*

Please describe anything else you feel is important for me to know

Questions

Which adults are important in your child’s life?

What children are important in your child’s life?

What responsibilities does your child have?

How does your child handle school/daycare?

How does your child get along with adults?

How does your child get along with other children/siblings?

Describe your child’s eating habits.

Describe your child’s sleeping habits.

What is your child most afraid of?

What does your child get angry about?

What does your child get sad about?

What hurts your child’s feelings?

Class Registration

Parental Information

Co-parental Information

Legal Questions

Child's Background

Questions

Personal Information

Medical History

Lifestyle

Chemical Use and Legal Issues

Checklist of Concerns