Adolescent & Family Information Form – AdolEssence

Adolescent's Name *

Personal Information

Date of Birth *

Personal Information

Other Name (Known As/Pronouns) *

Personal Information

Phone Number *

Email *

Mother's Name *

Personal Information

Mother's Email *

Personal Information

Mother's Phone No. *

Personal Information

Father's Name *

Personal Information

Father's Email *

Personal Information

Father's Phone No. *

Personal Information

Parent's Relationship Status

Married
Cohabiting
Separated/Divorced

Sibling 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 Information

Medical History/ Medication History *

Medical/ Psychological/ Behavioural Information

Does your adolescent have a medical diagnosis? *

Medical/ Psychological/ Behavioural Information

Does your adolescent have a behavioural diagnosis? *

Medical/ Psychological/ Behavioural Information

Does your adolescent have a specific learning diagnosis? *

Medical/ Psychological/ Behavioural Information

Does your adolescent have a Mental Health diagnosis? *

Medical/ Psychological/ Behavioural Information

Describe your adolescent's personality: *

Medical/ Psychological/ Behavioural Information

Describe your adolescent's interests or past-times: *

Medical/ Psychological/ Behavioural Information

Name of School: *

School Information

Class/Year: *

School Information

Has your adolescent received any additional educational supports in the past or currently? *

School Information

Has your adolescent been referred to any other service now or in the past? *

Psychology
Psychiatry
Speech and Language

Does your adolescent have any history of illness or accidents? *

Any additional information: *

Are both parents aware of this assessment? *

Yes
No
N/A

Parent/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 adolescent

G.P Name *

G.P. Information

G.P. Practice Name & Address *

G.P. Information