Please enable JavaScript in your browser to complete this form.Adolescent's Name *Personal InformationDate of Birth *Personal InformationOther Name (Known As/Pronouns) *Personal InformationPhone Number *Email *Mother's Name *Personal InformationMother's Email *Personal InformationMother's Phone No. *Personal InformationFather's Name *Personal InformationFather's Email *Personal InformationFather's Phone No. *Personal InformationParent's Relationship StatusMarriedCohabitingSeparated/DivorcedSibling Information (Name/Age/School/Health Service Attended *Sibling Information (if none, mark N/A)Who resides at home with your Adolescent? *Please provide dates of any assessments/diagnosis *Medical/ Psychological/ Behavioural InformationMedical History/ Medication History *Medical/ Psychological/ Behavioural InformationDoes your adolescent have a medical diagnosis? *Medical/ Psychological/ Behavioural InformationDoes your adolescent have a behavioural diagnosis? *Medical/ Psychological/ Behavioural InformationDoes your adolescent have a specific learning diagnosis? *Medical/ Psychological/ Behavioural InformationDoes your adolescent have a Mental Health diagnosis? *Medical/ Psychological/ Behavioural InformationDescribe your adolescent's personality: *Medical/ Psychological/ Behavioural InformationDescribe your adolescent's interests or past-times: *Medical/ Psychological/ Behavioural InformationName of School: *School InformationClass/Year: *School InformationHas your adolescent received any additional educational supports in the past or currently? *School InformationHas your adolescent been referred to any other service now or in the past? *PsychologyPsychiatrySpeech and LanguageDoes your adolescent have any history of illness or accidents? *Any additional information: *Are both parents aware of this assessment? *YesNoN/AParent/Guardian Consent; I……………………………………………….. parent(s) agree to the concents of this information sheet. I am aware that this information will be reviewed prior to the initial assessment and that its contents will be discussed during our first session. I hereby give persmioon for the Psychotherapist to contact services as needed to get further information on my adolescentG.P Name *G.P. InformationG.P. Practice Name & Address *G.P. InformationSubmit