Peacemaker Solutions, LLC / Jacqueline Oduselu, MS, NCC, LPC

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1905 Woodstock Road, Suite 7150, Roswell, GA 30075 • (404) 644-5523 • Fax (770) 212-2210

CLIENT INFORMATION FORM

*This Form is Confidential*

Today's date: ______

Your child’s name: ______

Last First Middle Initial

Parent or Legal Guardian’s Name: ______

Last First Middle Initial

Child’s date of birth: ______Gender: ______

Parent or Legal Guardian’s Social Security #: ______

Home street address: ______

City: ______State: ______Zip:______

Parent or Legal Guardian’s Name of Employer:______

Address of Employer: ______

City:______State: ______Zip:______

Home Phone: ______Work Phone: ______

Cell Phone: ______Email: ______

Calls will be discreet, but please indicate any restrictions:______

______

Referred by: ______

- May I have your permission to thank this person for the referral?

Yes No

-If referred by another clinician, would you like for us to communicate with one another?

Yes No

Person(s) to notify in case of any emergency:______

Name Phone

We will only contact this person if we believe it is a life or death emergency. Please provide your

signature to indicate that we may do so: (Your Signature):______

Please briefly describe your child’s presenting concern(s):______

______

What are your/your child’s goals for therapy? ______

______

How long do you expect to be in therapy in order to accomplish these goals (or at least feel

like you have the tools to accomplish them on your own)?______

MEDICAL HISTORY:

Please explain any significant medical problems, symptoms, or illnesses your child has had:______

______

Current Medications (if you need more room, please write on the back of this page):

Name of Medication Dosage PurposeName of Prescribing Doctor

Previous medical hospitalizations (Approximate dates and reasons): ______

______

Previous psychiatric hospitalizations (Approximate dates and reasons): ______

______

Has your child ever talked with a psychiatrist, psychologist, or other mental health professional? (If yes, please

list approximate dates and reasons): ______

______

Sexual & Gender Identity: __ Heterosexual __Lesbian __Gay __Bisexual

__Transgender __ Asexual __In Question __Other: ______

Racial/Ethnic Identity:

__African/African-American/Black __ Latino/Latino-American

__American Indian/Alaska Native__ Middle Eastern/Middle Eastern-American

__Asian/Asian-American/Asian Pacific Islander__White/European-American

__Bi-Racial/Multi-Racial __Not listed

LEGAL ISSUES

1. Does your child have any current legal issues?YESNO If yes, please describe:

2. Have they ever been arrested? YESNO If yes, please describe charges:

3. Are they currently on probation/parole?YESNO If yes, please describe for each charge:

4. Does your child have a DFACS worker?YES NO If yes, please describe:

5. List any and all violent crime charges your child has been charged with and their status:

6. List any pending charges or incidents involving the law:

FAMILY:

How would you describe your child’s relationship with his or her mother?______

______

How would you describe your child’s relationship with his or her father?______

______

Are the child’s parents still married or did they divorce?______If they divorced, how old was the

child when the parents separated or divorced and how do you think this impacted him or her?______

______

Please describe your child’s relationship with his or her grandparents: ______

______

Were there any other primary care givers who have had a significant relationship with your child? If so, please

describe how these people may have impacted your child’s life: ______

______
______

How many sisters does your child have? _____Ages? ______

How many brothers does your child have? ______Ages? ______

How would you describe your child’s relationships with his or her siblings?______

______

FAMILY HISTORY OF (Check all that apply):

Drug/Alcohol ProblemsPhysical Abuse Depression

Legal TroubleSexual Abuse Anxiety

Domestic ViolenceHyperactivity Psychiatric Hospitalization

SuicideLearning Disabilities “Nervous Breakdown”

SOCIAL SUPPORT, SELF-CARE, & EDUCATION:

POOR EXCELLENT

Child’s current level of satisfaction with friends and social support: 1 2 3 4 5 6 7

How would you describe your child’s relationships with his/her peers? ______

______

Please briefly describe any history of abuse, neglect and/or trauma: ______

______

Please briefly describe your child’s self-care and coping skills: ______

______

What are your child’s diet, weight, and exercise/activity patterns?______

______

Please briefly describe your child’s school performance and experience:______

______

What are your child’s hobbies, talents, and strengths?______

______

PLEASE CHECK ALL THAT APPLY TO YOUR CHILD CIRCLE THE MAIN PROBLEM:

DIFFICULTY WITH: NOW PAST DIFFICULTY WITH: NOW PAST DIFFICULTY WITH: NOW PAST

AnxietyTantrums Nausea

DepressionParents Divorced Stomach Aches

Mood ChangesSeizures Fainting

Anger or TemperCries Easily Dizziness

PanicProblems with Friend(s) Diarrhea

FearsProblems in School Shortness of Breath

IrritabilityFear of Strangers Chest Pain

ConcentrationFighting with Siblings Lump in the Throat

HeadachesIssues Re: Divorce Sweating

Loss of MemorySexually Acting Out Heart Problems

Excessive WorryHistory of Child Abuse Muscle Tension

Wetting the BedHistory of Sexual AbuseBruises Easily

Trusting OthersDomestic Violence Allergies

Communicating Thoughts of Hurting Often Makes Careless

with OthersSomeone Else Mistakes

Separation AnxietyHurting Self Fidgets Frequently

Alcohol/DrugsThoughts of Suicide Impulsive

Drinks CaffeineSleeping Too Much Waiting His/Her Turn

Frequent VomitingSleeping Too Little Completing Tasks

Eating ProblemsGetting to Sleep Paying Attention

Severe Weight Gain Waking Too Early Easily Distracted by Noises

Severe Weight LossNightmares Hyperactivity

Head Injury Sleeping AloneChills or Hot Flashes

Any additional information you would like to include: ________________________

Signature of Client (or person completing form): Date

Signature of Therapist Date