Confidential Information and History
All information disclosed to Neurotherapeutic Pediatric Therapies’ staff is confidential, except when a child is in danger of abuse or suicide,
is a clear and present danger to their-self or others or is the victim of a crime. An authorization for release of information must be signed by
a parent or youth before information can be given to the court, school, or third party in any other case not mentioned above.
Please complete this form as applicable
TODAY’S DATE ________________________
CLIENT INFORMATION
Legal First Name: ________________________________ Legal Last Name____________________________________________
Other Names Used: _________________________________________________________ Gender: _________________________
Preferred Name: _______________________________________ Age: ____________ DOB(mm/dd/yyyy): ____________________
Home Phone:___________________________________________ Cell Phone: __________________________________________
Email: ___________________________________________________________________________________________________
Children Living in Home:
_________________________________________________________________________________________________________
Marital Status:  SINGLE  MARRIED  DIVORCED  SEPARATED  WIDOWED  DOMESTIC PARTNERS
 NEVER MARRIED
 OTHER _____________________________
Occupation: ____________________________________________ Employer_________________________________________
Education: _______________________________________________________________________________________________
In Case of an Emergency, Whom do we contact? Name: _________________________________ Phone: ___________________
DHS Caseworker :________________________________________
First Name
Last Name
__________________________
County
_______________________
Phone
________________________________________________ (Foster/Adoptive Parent?)  Yes  No
(Biological Parent?)  Yes  No
Parent Marital Status:
Parent/Guardian:
 SINGLE  MARRIED
 NEVER MARRIED
 DIVORCED  SEPARATED  WIDOWED  DOMESTIC PARTNERS
 OTHER _____________________________
_______________________________________________ (Foster/Adoptive Parent?)  Yes  No
(Biological Parent?)  Yes  No
Parent Marital Status:
Parent/Guardian:
 SINGLE  MARRIED
 NEVER MARRIED
PERSON(S) LIVING WITH YOU
 DIVORCED  SEPARATED  WIDOWED  DOMESTIC PARTNERS
 OTHER _____________________________
AGE
QUALITY OF RELATIONSHIP: 1 “worst” – 10 “best”
RELATIONSHIP TO YOU
WORK HISTORY
Are you currently employed?
 No  Yes,
 Full time (30 or more hours)
 Part-time (less than 30 hours)
 Odd Jobs/Temporary
 Training Program
What kind of work do you do? _______________________________________________________________________
If yes is it:
Confidential Information and History
CURRENT PROBLEMS
Please describe briefly what changes you are hoping to make by coming to therapy now.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please mark only the symptoms below which you have experienced in the past 3 months.
___Relationship Issues
___Computer addiction
___Recurring, intrusive thoughts/memories
___Depression
___Feeling hopeless
___ Problems with pornography
___Obsessions or compulsions
___ Parenting Issues
___Change in sleeping habits
___Trouble concentrating
___Extreme sadness/crying spells
___Change in eating habits
___Memory problems/confusion
___Lack of energy
___Feelings of extreme happiness/excessive energy
___Weight changes
___Feeling stressed
___Change in sexual interest or function
___Self-esteem problems
___Feeling guilty
___Problems getting along w/others
___Anger/irritability
___Feeling fearful
___Trouble performing your job
___Feeling anxious
___Acting violently
___Lack of enjoyment of usual activities
___Lack of motivation
___ Fatigued
___Sudden feelings of panic
___Physical complaints of pain
___Thoughts of hurting yourself/others
___Thoughts of killing yourself/others
___Social Discomfort
___Muscle tension
___Flashbacks
___Hearing voices
___Visual hallucinations
___Suspicion/paranoia
___Racing thoughts
___Wide mood swings
___Nightmares
___Gambling problems
___Other: ___________________________________________________________________
Have you ever attempted/thought of hurting/killing yourself?  No  Yes If yes, explain
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SCHOOL STATUS
(For current or most recent grading period)
Name of School: __________________________________________________ Present Grade: _____________________
School Counselor: ________________________________________________ Grade Point Average: ________________
Number of Tardies: ______________ Number of Absences: _______________ Number of Suspensions: _____________
Number of Expulsions: ___________ Behavior Issues if any: ________________________________________________
Previous School History:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Confidential Information and History
SOCIAL
Spiritual? Religious? Church/Spiritual Community?  No  Yes
If yes, how important is it?
_________________________________________________________________________________________________
Do you have social support?  FAMILY  NEIGHBOR  FRIENDS  CO-WORKERS  OTHER: ______________________
If so, who?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
What are the hobbies/activities that you find pleasure in?
_________________________________________________________________________________________________
MEDICAL INFORMATION
Height ___________
Weight __________
Race/Ethnicity _________________________________________
Your Physician: _____________________________________________
Date of Last Exam: ___________________
Facility: ___________________________________________________
Phone: _____________________________
Prescription/Non-Prescription medication(s) currently taking:
Name of Medication
_____________________________________
Dosage
_______________________
Date of Initial Rx/Physician Prescribed
____________________________________
_____________________________________
_______________________
____________________________________
_____________________________________
_______________________
____________________________________
_____________________________________
_______________________
____________________________________
_____________________________________
_______________________
____________________________________
Past/current medical problems/surgeries:
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Please describe the following as it applies to you:
Frequency/quantity of alcohol consumption _____________________________________________________________
Quantity of cigarette smoking ________________________________________________________________________
Amount of caffeine consumption ______________________________________________________________________
Frequency/type of physical exercise ____________________________________________________________________
Amount/quality of sleep _____________________________________________________________________________
Please indicate if any of the below apply. If possible, also include dates. If not applicable, please indicate “N/A”.
Surgeries: ________________________________________________________________________________________
Broken Bones: ____________________________________________________________________________________
Head Injuries: _____________________________________________________________________________________
Seizures: _________________________________________________________________________________________
Infectious Diseases: ________________________________________________________________________________
Abnormal Kidney Functions: _________________________________________________________________________
Abnormal Liver Functions: _________________________________________________________________________
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Confidential Information and History
Allergies: a.) Food: ________________________________________________________________________________
b.) Medications: ________________________________________________________
c.) Other: ______________________________________________________________
Heart or Lung Dysfunctions: _________________________________________________________________________
Skin Infections: ___________________________________________________________________________________
Diabetes:
________________________________________________________________________________________
Tuberculosis: _____________________________________________________________________________________
Drug/Alcohol Withdrawal: __________________________________________________________________________
Intravenous Drug Use:
_____________________________________________________________________________
Hepatitis/HIV/Infectious Diseases: ____________________________________________________________________
Other: ___________________________________________________________________________________________
Hospitalizations:
__________________________________________________________________________________
Are you sexually active?  No  Yes
Primary Care Physician: ________________________________ Facility Name: _____________________________
Address: _____________________________________________________ Phone: ______________________________
PREVIOUS MENTAL HEALTH TREATMENT
Outpatient:
 No  Yes
Inpatient
 No  Yes
Drug/alcohol:  No  Yes
Group:
 No  Yes
Have you or your family ever attended therapy/counseling before?  No  Yes
If yes, please describe below:
1. Name of therapist/counselor/agency ________________________________________________________________
Did you go alone or with your family? _____________________________________Dates: ____________________
Reason: _______________________________________________________________________________________
2. Name of therapist/counselor/agency ________________________________________________________________
Did you go alone or with your family? _____________________________________Dates: ____________________
Reason: _______________________________________________________________________________________
FAMILY MENTAL HEALTH HISTORY
Describe any mental health issues within your immediate family:
_________________________________________________________________________________________________
Are any of your family members frequent drug or alcohol users?  No  Yes, If yes, which members?
_________________________________________________________________________________________________
DRUG/ALCOHOL HISTORY
Have you, or are you currently using drugs or alcohol?  No  Yes
If yes, at what age did you begin drinking alcohol? ________________________________________________________
If yes, at what age did you begin using drugs? ____________________________________________________________
What types of drugs (including alcohol) have you or are you presently using?
________________________________________________________________________________________________
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Confidential Information and History
How many drinks does it take for you to feel drunk? ______________________________________________________
Have you ever experienced a memory loss during drinking? ________________________________________________
Have you ever overdosed from drugs/alcohol? ___________________________________________________________
TRAUMA/LOSS HISTORY
 Verbal/emotional abuse
 Domestic violence
 Loss of loved one
 Physical abuse/neglect
 Immigration trauma
 Violence in the home
 Sexual abuse/molestation
 Elderly abuse
 Parent illness (mental health or medical)
 Car accidents
 Teen pregnancy
 Financial problems
 Crime or other community violence
 Foster placement
 Homelessness
 Parent substance abuse
 Other:
BIRTH HISTORY
Describe any issues while mother was pregnant with client.
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Did birth mother abuse drugs/alcohol during pregnancy?
 Yes  No
Were developmental milestones met appropriately? (i.e., sitting up as infant, walking, talking on time with average child
development)?
 Yes  No. if no, please describe
_________________________________________________________________________________________________
LEGAL HISTORY
Have you ever gotten into any legal problems?  No  Yes If yes, explain
__________________________________________________________________________________________________
Ever been convicted of a misdemeanor or felony?  No  Yes If yes, explain
__________________________________________________________________________________________________
Please list any previous charges or arrests (include runaway, curfew violation, MIP, etc.)
__________________________________________________________________________________________________
Number of arrests/charges in the last 24 months: ______________
Have any of these charges been drug/alcohol related? ______________________________________________________
Are you currently involved in divorce or child custody proceedings?  No  Yes Previously?  No  Yes
If yes, please explain: ________________________________________________________________________________
Is DHS Involved?  No  Yes If yes, why?
__________________________________________________________________________________________________
Are you court ordered to attend Mental Health Treatment?  No  Yes
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