Student's Name
*
First Name
Last Name
Gender
Date of Birth
*
MM
DD
YYYY
Age:
*
Email:
*
Address:
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Who (parent/legal guardian) will be accompanying the student for each session?
*
First Name
Last Name
Gender
Relationship to Student:
Mother/Legal Guardian Name:
First Name
Last Name
Age:
Preferred Phone #:
"By providing your phone number, you agree to receive text messages from Watershed Ministries. Message and data rates may apply. Message frequency varies."
(###)
###
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment status & description:
Marital Status:
Step-parent name:
First Name
Last Name
Father/ Legal Guardian Name:
First Name
Last Name
Age:
Preferred Phone #:
"By providing your phone number, you agree to receive text messages from Watershed Ministries. Message and data rates may apply. Message frequency varies."
(###)
###
####
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Employment status & description:
Marital Status:
Step-parent name:
First Name
Last Name
Describe, if applicable, custody agreement:
Requested copy of separation agreement for EMR:
Describe student's siblings and placement:
Describe student's living arrangements:
Describe other significant supports:
Describe parenting style(s):
Describe current or past DSS-Child Protective Services and outcomes:
Describe student’s spiritual/faith-based beliefs:
School Name:
Grade:
Teacher(s) Name:
Describe student's attitude about school and any stressors:
IEP or 504 Accommodations/AG Program:
List any current/prior suspension(s) or behavioral problems:
Describe student’s friendships:
Describe any concerns related to bullying:
List hobbies and interests:
Amount of daily screen time (ie, Phone, Tablets, CPU, TV, Gaming, Other):
Social Media use & concerns (ie, Internet, texting, Instagram, Gaming, etc.):
Pediatrician/Primary Care Provider:
Date of last exam:
List any Medical or Psychiatric hospitalizations:
Describe any medical conditions related to counselee:
List current medications and prescribing physician:
Enuresis/Encopresis:
Describe student's sleep cycle:
Describe student's diet/appetite:
Allergies/Adverse Reactions:
Sexually active?
Yes
No
Unsure
Explain, if applicable:
Describe relevant history (prenatal care; full-term/preemie, complications, developmental milestone, etc.):
List any speech, occupational, physical therapies and outcomes:
Student's Maternal family:
Student’s Paternal family:
Please describe event(s), treatment, and outcomes.
Student’s substance use/abuse:
*
Yes
No
Unsure
Describe use history:
Describe:
Safety Plan:
Describe student’s and parental commitment to treatment, including any barriers:
Does the student believe in God?
Would you say they have a personal relationship with God?
How frequently do they read the Bible?
How often do they pray?
Church presently attending:
Average times attended per month:
Do they enjoy attending church?
Describe the overall presenting problem:
Do you give permission for Watershed Ministries to contact you by Phone, Text and/or Email?
*
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Where did you hear about Watershed Ministries? Who referred you?