New Client Application Form Date___________________________________ Referred by_______________________________ Student Name ______________________ ______________________ _______________________
DOB_______ ______ ________ Current Age_______ Ethnicity_____________________________ Yr. in School______ Middle School______________________ High School___________________ Height__________________ Weight__________________ Adopted _____yes _____no Current Medications Dosage Amount of Time Taken ______________________________________ ___________ ______________________________ ______________________________________ ___________ ______________________________ ______________________________________ ___________ ______________________________ Mother (Guardian) Father (Guardian) Name___________________________________ Name___________________________________ Address________________________________ Address_________________________________ __________________________________ ___________________________________ Home Phone_____________________________ Home Phone______________________________ Work Phone_____________________________ Work Phone______________________________ Cell Phone_______________________________ Cell Phone_______________________________ Fax____________________________________ Fax_____________________________________ Email___________________________________ Email___________________________________ Occupation______________________________ Occupation______________________________ Highest Educational Level__________________ Highest Educational Level____________________ Marital Status _____married _____separated ____divorced If divorced, custody arrangements? Legal ___fa ___mo Custodial ___fa ___mo
STUDENT INFORMATION What are the primary issues your child faces?__________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Does your child have any learning or attention issues? ____yes ____no If yes, please list or describe:_______________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Does your child exhibit emotional, psychological or behavioral difficulties? ___yes ___no If yes, please describe:___________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Primary Strengths:______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Primary Weaknesses:____________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Interests/Hobbies:______________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
FAMILY INFORMATION Siblings Age Natural/Step _____________________________________________ ___________ ________________ _____________________________________________ ___________ ________________ _____________________________________________ ___________ ________________ _____________________________________________ ___________ ________________ Religious/Spiritual Orientation __________________________________________________________________________ __________________________________________________________________________ Current Family Composition Primary Household Second Household Name Relationship Name Relationship ________________ ____________________ _________________ ________________________ ________________ ____________________ _________________ ________________________ ________________ ____________________ _________________ ________________________ ________________ ____________________ _________________ ________________________ ________________ ____________________ _________________ ________________________ ________________ ____________________ _________________ ________________________
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