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*

    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