client inform - Ciiem infwmafion Today’s date Your...

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Unformatted text preview: Ciiem infwmafion Today’s date: Your Child’S Name Date of Bifih ; f Your Child’s Scciai Security # :u ‘1“ Home Phone ‘. Occupaticn 'a F‘ “ 4 TN ; , g 1 ,—. Same: becwrzzy n— ‘ ~ 5 crs ! canne- i Name of Business & Address W E I! I f E § ‘: Acdress map/12's T 1 MM m s! E3 ’1 n. a . 7- -«fi “a. —— E ; pageants mamas; H5018 _, g 3 W W E ‘ Nam” cf business iccress _ g Scciai Securét‘ 2i Savers Licerae "4‘ J1 r» ‘ 1 - H .N i mihng Adams: 5 fl 1 E l - n . Ir rm: r- ! 3" I I‘ V'. ‘ How war»: qu mews: LG New Dir-:caona? } 1 3 ; ’ a. ,n i L i A 5,... A ; ,. ! ; Can we mam his ;E:\-:F=:F‘:L7 l f 3 Client History Ciient Name Date What incidents or behaviors first caused you to be concerned about the possibility that your son or daughter might be using or drinking? (Missing money, liquor etc.) Priorto coming to this program. what actions were undertaken to address the issue of your chiid’s chemical use“? W W W W At this time, what prooiems do you direcfly attribuie {o your chii "s shemicei use? WW N‘net cfrugs so you :eiieve your child is using inducing mosses”? WWW in "Nfiat ways does your rhifio‘ become aggressive or amen/e Has your ohiid participated in any kind of counsefing prior to coming to this program? Name of counseIor fromlto presenting issue reason for or program termination Medical! History A. Your Chiid’s Medical Histom 4.. Doctors name: § W z § 2‘ Date onas‘t ohysicai W g 3, Childhocdiimess” i i i E W I § $5 5;. Hosoitaiizaticns , ‘ “““_‘_“‘—“‘“” '—' " “ "‘ ‘ ‘—"‘ '_ ‘ “_ ‘ " ' ' i :3 Ailergées mower-good} 3 WW“ 5 Q g 2 5 iaamnrg oreacmireo Q W WWW“ ! g . ”w. -‘. ‘.,..;. ' r-x ‘szlfifi‘Fs‘Lgy «mag 8’71,“ :TEGCFCEUCRS .’ 9. Curreot‘iy iakirtg any amzaminiménerai succiements’? - M : fl ‘lfli‘ha‘c other énformatier atom *xcur amid or famiiy wouio‘ be oeéofwi 3% , 2 I a . i i l E 2 Family History Client Name Date (The following information will not be shared with your child by the counseling staff) Family Medical Histom (Dad, Mom, Maternal Grandmother & Grandfather, Paternal Grandmother & Grandfather and other family members). 1. Currently or in the past, has anyone in your family ever had a problem with alcohol? (your child’s maternal and paternal sides) “W W W a Have any family membere sought treatment“? if \ ee. who () 1‘) M.‘ (I) ll) .3 “i: 11 ‘J l miiy members in recovery? if yea who 3. Currently or in the east, has anyone in your family ever had- a problem with druge T'fl‘l‘r oh'io’s maternal -4 WWW Wm ~ - "A r‘: nd eatern lowest.» 1}) (‘1 I J 1 e. Are any famiiy members in recovery? if yes, who? W 2. Currentiy or in the past, has anyone in your famiiy used nicotine? W WWW—WWW 3. Has any femiiy member successfuiiy quit smoking or chewing”? if yes, who? WWW—MW WWW—«WW 3. What is "0L1ro.’:iid sm err‘ ai and paterne ai famiiy history of food addictions (overeating buiimia er:- xia asuger addictions? e. Hes any“? miiy member eeen: ere: so for food addiction? if yes, who"? % WW Nhoir .the SI. iiy has e i oiszorr o —'1 i L {D U '3 (I) (fl 9} O "3 o. What iS your ehiid’ s mar rerne iend eetemei femiiyhisrory or” memre! iiiriess f for exempie manic depression, oi-eoier rfiiscrder. anxietydisoroers, schizophrenia or \) personeiity disorders) 1 ‘1 M4... ”My-«M- ”mam“ _A.A,n.._........__.i..‘. Mmmmmiqk ...
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