Alan Behrman & Associates, PC

2876 Johnson Ferry Rd., Suite 150 Marietta, GA 30062
770-361-7864 [email protected]


Client Information Form

*This form is completely confidential*

Today's date :

Parent or Legal Guardian’s Name

Child’s date of birth:

May I have your permission to thank this person for the referralYesNo

If referred by another clinician, would you like for us to communicate with one another?
YesNo

Person(s) to notify in case of any emergency:

We will only contact this person if we believe it is a life or death emergency. Please provide your name to indicate that we may do so:


*The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.*

MEDICAL HISTORY:

Current Medications:


FAMILY:

Were there any other primary care givers who have had a significant relationship with your child? If so, please describe how these people may have impacted your child’s life:


SOCIAL SUPPORT, SELF-CARE, & EDUCATION:


Please check all that apply:

Anxiety

Depression : NowPast
Mood Changes : NowPast
Anger or Temper : NowPast
Panic : NowPast
Fears : NowPast
Irritability : NowPast
Concentration : NowPast
Headaches : NowPast
Loss of Memory : NowPast
Excessive Worry : NowPast
Wetting the Bed : NowPast
Trusting Others : NowPast
Communicating with Others : NowPast
Separation Anxiety : NowPast
Alcohol/Drugs : NowPast
Drinks Caffeine : NowPast
Frequent Vomiting : NowPast
Eating Problems : NowPast
Severe Weight Gain : NowPast
Severe Weight Loss : NowPast
Head Injury : NowPast

Tantrums

Parents Divorced : NowPast
Seizures : NowPast
Cries Easily : NowPast
Problems with Friend(s) : NowPast
Problems in School : NowPast
Fear of Strangers : NowPast
Fighting with Siblings : NowPast
Issues Re-Divorce : NowPast
Sexually Acting Out :NowPast
History of Child Abuse : NowPast
History of Sexual Abuse : NowPast
Domestic Violence : NowPast
Thoughts of Hurting Someone Else : NowPast
Hurting Self : NowPast
Thoughts of Suicide : NowPast
Sleeping Too Much : NowPast
Sleeping Too Little : NowPast
Getting to Sleep : NowPast
Waking Too Early : NowPast
Nightmares : NowPast
Sleeping Alone : NowPast

Nausea

Stomach Aches : NowPast
Fainting : NowPast
Dizziness : NowPast
Diarrhea : NowPast
Shortness of Breath : NowPast
Chest Pain : NowPast
Lump in the Throat :NowPast
Sweating : NowPast
Heart Problems : NowPast
Muscle Tension : NowPast
Bruises EasilyNowPast
Allergies : NowPast
Often Makes Careless Mistakes : NowPast
Fidgets Frequently : NowPast
Impulsive : NowPast
Waiting His/Her Turn : NowPast
Completing Tasks : NowPast
Paying Attention : NowPast
Easily Distracted by Noises : NowPast
Hyperactivity : NowPast
Chills or Hot Flashes : NowPast


FAMILY HISTORY OF (Check all that apply):

Drug/Alcohol ProblemsLegal TroubleDomestic ViolenceSuicide
Physical AbuseSexual AbuseHyperactivityLearning Disabilities
DepressionAnxietyPsychiatric HospitalizationNervous Breakdown