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SarahSouderJohnson,MEd,LPCC
AnxietyTherapyGroupforTeens
TeenAnxietyTherapyGroupIntake
Thisformmayseemlong,buttheinformationonitwillhelpmetobetterunderstandyou.The
informationonthisformisconfidentialunlessithastodowithhurtingyourselforsomeoneelse.
AdolescentDemographicInformation
Name:_______________________________________________________
Address:_____________________________________________________
____________________________________________________________
Gender:_________________Age:____________DateofBirth:_____________
HomePhone:__________________________________Isitokaytoleaveamessage:Yes/No
(pleasecircleone)
ClientCellPhone:________________________________Isitokaytoleaveamessage:Yes/No
(pleasecircleone)
ParentCellPhone:_______________________________Isitokaytoleaveamessage:Yes/No
ParentsorLegalGuardians:__________________________________________________
Withwhomdoyoulive?_____________________________________________________
Howdidyouhearaboutourgroup?____________________________________________
Doyouhavesiblings?Ifyes,howmany?Pleaselisttheirnamesandages:
_______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Wereyouadopted?(Pleasecircle)Yes/No
Ifyouanswered“Yes”totheabove,atwhatagewereyouadopted?________________
Haveyoueverbeeninfostercareorasimilarlivingarrangement?(Pleasecircle)Yes/No
Ifyouanswered“Yes”totheabove,atwhatageswereyouincare________________
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SarahSouderJohnson,MEd,LPCC
AnxietyTherapyGroupforTeens
Whatschooldoyougoto?_____________________________________Grade:________
Doyoulikeattendingthisschool?Areyouhavinganydifficulties?
________________________________________________________________________
________________________________________________________________________
ReligiousAffiliation:_________________________________
Religious/spiritualtraditionsyouwouldlikemetoknowabout:
________________________________________________________________________
________________________________________________________________________
Whatareyourhobbies/interests?
________________________________________________________________________
________________________________________________________________________
Assessment:
Pleasecheckany/allofthesymptomsyouarehaving:
Depression
FeelingHopeless
ExtremeSadness
ProblemsGettingAlongwith Family
TroubleConcentrating
ChangeinSleepingHabits
MemoryProblems
LackofEnergy
ChangeinEatingHabits WeightChanges
ExtremeHappiness
FeelingTearful
Troublegoingtoschool ProblemswithGettingAlong withFriends
LackofEnjoymentin
FeelingStressed
UsualActivities
Obsessions/Compulsions EasilyIrritated
FeelingFearful
FeelingGuilty
PhysicalComplaintsof
FeelingWorriedorAnxious
Pain
ProblemswithAnger
SuddenFeelingsofPanic
UnusualDreams
MuscleTension
DrugorAlcoholUse
ActingViolent
ThoughtsofHurting
ThoughtsofKillingYourself
YourselforOthers
orOthers
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SarahSouderJohnson,MEd,LPCC
AnxietyTherapyGroupforTeens
Doyoucurrentlyseeanothertherapist?(Yes/No)Ifso,whatistheirname?
___________________________________________________________________
___________________________________________________________________
HaveyoubeendiagnosedwithaLearningDisorder?Ifso,whichone(s)?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
History:
Haveyoueverexperiencedanycriticaleventsoraneventthatyouconsidertraumatic?
________________________________________________________________________
________________________________________________________________________
CurrentSupportGroup:
Whatwouldyouliketogetoutofthisgroup?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Whatelsewouldyoulikemetoknowaboutyouatthistime?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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SarahSouderJohnson,MEd,LPCC
AnxietyTherapyGroupforTeens
Parents:
Pleasefeelfreetoaddanythingyouwishbelow(additionalinformationyouwouldlikethe
therapisttoknow,goalsyouhaveforyourteen,etc.).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Thankyoufortakingthetimetocompletethisform.Thisinformationwillbeveryhelpfultothe
therapistandyourgrouptherapy/yourteen’sgrouptherapy.
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