Main Street Counseling Solutions
Meet the Team
Contact & FAQs
Client First & Last Name
Client Birthday & Age
Parent 1 First & Last Name
Parent 1 Email Address
Parent 2 First & Last Name
Parent 2 Email Address
Parent 1 Relationship to Client
Parent's Marital Status
Parent 1 Phone Number
Parent 1 Address (If Different)
Parent 2 Phone Number
Parent 2 Address (If Differnet)
Parent 2 Relationship to Client
If separated or divorced, please explain custody agreement
Family Members Living in the Home
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Any Other Family Members
Other Providers (psychiatrist, speech therapist, etc.)
Reason for Seeking Treatment
Primary Reason for Seeking Treatment
History of Problems
Date Mother Started Prenatal Care
Please List Any Difficulties or Complications Biological Mother Experienced During Pregnancy?
Where any of the below used during the pregnancy
Used Any Other Drug (cocaine etc.)
Wher any medications used during the pregnancy?
Labor & Delivery (length of pregnancy, type of birth, complocations during delivery, etc.)
Baby's Weight & Length
APGAR Scores at Delivery
Please List Any Newborn Complications
As an infant, was there anything unusual or difficult about this child within the first 12 months of life?
Describe your child's personality as a baby?
Please Select Any Developmental Milestones That Your Child Met
Make eye contact
Say first word
Speak in sentences
Self feed with utensils
Drink from a cup
Play with others interactively
Rides a bicycle
Please check any problems your child had/has as an infant or young child?
Rocking or hand flapping
Unresponsive to questions
Used incorrect promouns to refer to self/others
Never or rarely began a conversation
Talks to self and not others
Restless or overactive
Does not listen to rule following
Please list any milestones that your child did not meet or was delayed.
Please list any checked problems
Please list any sensory problems your child had/has
Does your child have/had any problems with sleep or appetite?
Had/Does your child have any problems with transitions, adapting to new environments, and/or seperation issues?
Did your child ever recieve speech or occupational therapy? If so for what and how long?
My child's immunizations are up to date
Child ever been hospitalized? When? Why? Length & Treatment?
Any history of serious injury?
Any history of surgery? When? Why?
Does your child have any allergies? Have they ever had a life threatening allergic reaction(s)?
has your child experienced any medical isses? (headaches, heart problems, dizziness, infections, seizures?)
History of medications. Please include why they were prescribed and length of prescription
Please list any current medications your child is taking
Has your child tried or currently use alcohol, tobacco, marijuana, or any illegal substances? Please indicate substance, when used, frequency of usage, and if they have stopped.
Does your child have any trouble at school or at home with the law? Please explain (because of substance use? behavior?)
Does your child have any history of ear infections or hearing problems?
Date of last hearing screening
Does your child have any history of vision problems or vision therapy?
Date of last vision screeing
Age of first menstrual period. Is it regular? Any difficulties related to menstrual period?
Describe child's relationships with parents or caregivers (past and current)
Describe child's relationship(s) with siblings (past and current)
Describe your child's current peer relationships
What are your child's strengths & weaknesses?
What does your child like and dislike about themselves?
Has your child been picked on, teased or bullied? Has your child picked on, teased or bullied others?
How does your child respond to peer pressure?
Does your child have or have they had a significant other?
List your child's interest, hobbies, sports, etc.
History of legal or police involvement with child/anything child would be aware of or impacted by?
Any history of abuse (sexual, physical, emotional)
At what age and where did your child begin school?
Is your child receiving special education services? If yes, explain the accommodations. Has your child ever repeated a grade?
Does your child refuse to go to school?
Has your child been suspended or expelled from school?
What is your child's best and most challenging school subjects?
Has your child had any educational or psychological testing done?
Please describe any family members medical illnesses
Please describe any family history of mental illness
Thanks for submitting!