IMPORTANT: This form is to be completed by the minor or child in his or her own words. Fill as much as you can but if you are not sure what to write in some of the questions, that is OK. We can talk more when we meet up. Your parents will be sent a separate set of questions so they can tell me what they think and I need some information from them about your health and background that will help me understand your difficulty better. You need to know that whatever you tell me is confidential between us, unless your safety is under threat. I will always discuss this with you first.
*** PERSONAL DETAILS AND HISTORY
Full legal name
What name do you prefer to be called?
Date of birth
Contact (Mobile / Home / Work)
*** EXPERIENCE AND EXPECTATIONS
Are you here of your own choice?
Your parent/caregiver has made an appointment for you to come and see me. What do you think about that? Do you have any idea what it is about?
In your opinion, what do you find most difficult to deal with. Has it got to do with school? friends? family? studying? confusion? feelings? thoughts? or something else? Please write as many things that you can think of, that relates to the difficulties you may have been experiencing.
*** PAST AND CURRENT THERAPY HISTORY
Have you been or are you still seeing a counsellor / psychologist or other therapist for any reason? Please tell me in your own words how you feel or think about it.
If someone could help you, what would you want them to help you with?
*** MEDICAL HISTORY
Do you have any health problems?
*** PERSONAL AND FAMILY BACKGROUND
What year at school are you doing now? Which school are you attending?
How do you feel about school and making friends?
Is there anything else you would like me to know about you or your family?
*** RELIGIOUS OR SPIRITUAL BACKGROUND
What religion would you say you and your family are practicing?
What do you think about life?
*** ADDITIONAL INFORMATION
Is there any additional information you think I should be aware of?
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