Client Information Form - Youth - FAMILY HEARTBEAT INTERNATIONAL NETWORK

Client Information Form - Youth

Identification

* Indicates required field

Full Name *

First

Last

Date of Birth (m/d/y) *

Current Age *

Address *

Parent/Guardians Information

Name(s) *

Phone Number *

Relationship *

Address (if different to the one provided above) *

Education/Training/Employment

Status *

Student Employed Unemployed Other

Specify Other *

If a student, which school/institution: *

If employed, what is your occupation: *

Name of employment company: *

Family Background

How would you describe your relationship with your parents? *

Healthy Conflictual

How would you describe your childhood? *

Happy Unhappy

Are you closer to one parent than the other? *

Yes No

If Yes, who? *

Mother Father

Please provide details *

Do you have any siblings? *

Yes No

Please provide details, e.g. brothers/sisters, how many: *

Religious and Racial/Ethnic Identification

Current religious denomination/affiliation *

Which (if any) church do you/did you attend? *

How often do you attend church? *

Involvement *

None Some/Irregular Active

Do you believe in God? *

Yes No Uncertain

Do you pray to God? *

Yes No Uncertain

One a scale of 0 – 5, Please answer the following questions

How important are spiritual concerns in your life? *

Ethnicity/national origin *

Race *

Is there any other way you identify yourself and consider important: *

Personality Information

Which of the following best describe you right now?

Have you ever felt like people were watching you? *

Yes No

Do people’s faces ever seem distorted? *

Yes No

Do colours seem too bright? *

Yes No

Are you able to judge distances? *

Yes No

Have you ever had hallucinations? *

Yes No

Are you afraid of being in a car? *

Yes No

Referral

Have you seen a counsellor before? *

Yes No

If yes, who/where? *

If yes, what was the reason for you seeing a counsellor before? *

If yes, did you find it helpful seeing a counsellor? *

Yes No

Please explain *

Reason for Service

Were you referred to see a counsellor? *

Yes No

Specify Other *

If yes, what do you believe is the reason they have referred you to see a counsellor? *

Do you agree with their concerns? *

Yes No

Explain *

Are there any concerns, either those stated above or others which you would like to address through counselling? *

Is there anything else you would like to share about yourself that may be helpful as we work together? *

Submit Form

Welches | St. Michael | Barbados