Therapy for Kids & Teens

Preferred name of the person filling out this form *

Must be a parent or guardian.

First Name

Last Name

Your Legal Name *

First Name

Last Name

Your Date of Birth *

MM

DD

YYYY

Phone

(###)

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Is it ok to leave a voicemail at this number? *

Yes

No

Preferred communication method *

Email me.

Text me.

Call me.

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's legal name *

First Name

Last Name

Child's preferred name

First Name

Last Name

Child's date of birth *

MM

DD

YYYY

Are you currently or will you be engaged in custody or legal proceedings? *

Disclaimer: our establishment does not engage in custody suits or meditation. Under the licenses our clinicians practice we are unable to conduct assessments so If you are seeking services for custody and legal reasons please know we will be unable to support you. Let us know and we will gladly provide you with appropriate recommendations.

Yes

No

I'm not sure

Name of Person as listed on the insurance card

First Name

Last Name

Date of birth associated with insurance

MM

DD

YYYY

Address on file with insurance

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number on file with insurance

(###)

###

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What symptoms is your child/teen experiencing? *

Sleep problems

Morbid thoughts

Lack of interest in activities

Suicidal thoughts or threats

Unassertive suicidal plans / attempts

Fatigue / low energy

Mood swings

Concentration problems

Depression

Appetite / weight changes

Changed level of activity

Withdrawal

Cries easily

Forgetful / memory problems

Talks excessively / interrupts

Short attention span

Easily distracted

Aggressive behavior

Irritable

Can't sit still

Impulsive

Not interested in peers

Difficulty following rules

Picked on / bullied by peers

Problems completing schoolwork

Excessive worry / fearfulness

Nightmares

Anxiety or panic attackes

Frequent tantrums

Social fears

Shyness

Resistant to change

Separation problems

School refusal

Bedwetting / soiling

Perfectionism

Headaches

Stomach aches

Odd hand / motor movements

Odd beliefs / fantisizing

Hallucinations

Lying

Stealing

Trouble with the law

Being destructive

Running away

Fire setting

Truancy (skipping school)

Hurting others / fighting

Crossing boundaries sexually / exploring other kids bodies

Acts as if they have no fear

Alcohol / drug use

Short tempered

Argumentative / defiant

Easily annoyed

Annoys others

Swears

Discipline problems

Blames other for mistakes

Angry and resentful

Other (describe in box below)

Has your child been in therapy before? *

Yes

No

Does your child/teen want to come to therapy or is this at your urging? *

My child asked to go to therapy.

My child hasn't asked to go to therapy, but I'm encouraging them to go.

I'm not sure.

Are you open to doing joint sessions if I feel they would be beneficial to your teen/child? *

Yes

No

I'm not sure

At this time Frankie Forrester is the only clinician who has experience in working with children and teens. If Frankie is unavailable would you like to remain on their waitlist? *

I'd like to be placed on my Frankie's waitlist.

I'll keep searching for a therapist elsewhere, please send me a list of trusted referrals.

In-person sessions vs Telehealth? *

If your child is under 12, we only offer in-person sessions at Frankie's office, as they us activities, art, and play to conduct therapy. For teens 12 and up, we offer the option of Telehealth.

My child can come to in-person sessions.

My teen wants telehealth sessions.

My teen wants in-person sessions

I'm not sure yet.