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  • Adolescent Information Form

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    Terry
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    Problems Checklist - Rate Each Issue with a Number 1 = Major Problem 2 = Problem at Times 3 = Not a Problem ______ Feeling Accepted by my peers ______ Learning how to trust others ______ Getting along with my parents or other family members ______ Getting a clear sense of what I value ______ Dealing with sexual feelings and / or problems ______ Worrying about my future ______ deciding on a career ______ Dealing with alcohol or drug abuse ______ Who do you currently live with? ______________________

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    Problems Checklist - Rate Each Issue with a Number 1 = Major Problem 2 = Problem at Times 3 = Not a Problem ______ Feeling Accepted by my peers ______ Learning how to trust others ______ Getting along with my parents or other family members ______ Getting a clear sense of what I value ______ Dealing with sexual feelings and / or problems ______ Worrying about my future ______ deciding on a career ______ Dealing with alcohol or drug abuse ______ Who do you currently live with? ______________________

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    39 views1 page

    Adolescent Information Form

    Uploaded by

    Terry
    Problems Checklist - Rate Each Issue with a Number 1 = Major Problem 2 = Problem at Times 3 = Not a Problem ______ Feeling Accepted by my peers ______ Learning how to trust others ______ Getting along with my parents or other family members ______ Getting a clear sense of what I value ______ Dealing with sexual feelings and / or problems ______ Worrying about my future ______ deciding on a career ______ Dealing with alcohol or drug abuse ______ Who do you currently live with? ______________________

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
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    of 1

    Teresa (Terry) Winston, MA, LPC

    651 274-1006
    ADOLESCENT INTAKE
    Name _____________________________________________

    Age_______________

    Address ___________________________________________

    Phone _____________

    School _______________________________ Grade _________ Birthday __________


    Email address ___________________________________________________________
    Hobbies ________________________________________________________________
    Job ____________________________________________________________________
    Problems Checklist - Rate Each Issue with a Number
    1 = Major Problem 2 = Problem at Times

    3 = Not a Problem

    ______ Feeling Accepted by my peers


    ______ Learning how to trust others
    ______ Getting along with my parents or other family members
    ______ Getting a clear sense of what I value
    ______ Dealing with sexual feelings and/or problems
    ______ Worrying about my future
    ______ Trying to decide on a career
    ______ Dealing with alcohol or drug abuse
    ______ Dealing with problems at school
    ______ Dealing with how I feel about myself
    Additional problems Id like to talk about:__________________________________________
    Who do you currently live with? __________________________________________________
    What is their relationship with you? _______________________________________________

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