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Minor child/Dependent information form

Please complete as much of the form as you are able to.

Mark as "n/a" or leave blank sections that do not relateĀ  to your situation.

Please "click" on the agreement checkbox at the end and sign

 

Please complete this form prior to your session with your child/dependent's counselor

format: MM/DD/YYYY

Family Structure

Father
Mother
Both
Grandparents
Other adults in home

In Case of Emergency (ICE) Contact & Medical Information

Background

Anger
Phobias
Anxiety
Unhappiness
Depression
Stress
Nervousness
Decision making
Negative thoughts
Abuse/trauma
Fears
Friends
Future
Memory
Loneliness
Unhappy at school
Education discipline
Concentration
Ambition
Self-esteem
Disruptive in class
Making friends
Sleep
Nightmares
Fatigue
Trouble relaxing
Energy level
Under eating
Over eating
Health issues
Stomach problems
Headaches
Sexual identity
Suicide thoughts
Suicide threatened
Suicide planned
Suicide Attempted
Cutting
Self harm
Self control
Extreme isolation
Locking in rooms
Harm to others
Drug Use

School Information

Family HIstory

Minor or Individual with a Guardian Agreement

I/We the parent(s) guardian of the minor or individual with a guardian, as listed below, have completed the above information for Pathways Counseling
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Your Name
Your Name
Your Name
format: MM/DD/YYYY
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Your Name
Your Name
format: MM/DD/YYYY
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