Client Name * Client Date of Birth * Guardian or Caregiver Name * Phone Number * Street Address * City * State * Zip Code * Gender * Insurance Agency * Insurance RIN/Member# * Reasons for Seeking Counseling CHECK ALL THAT APPLY: ADHD Selected Anger Management Selected Anxiety Selected Behavior/Conduct (i.e. opposition and defiance, child behaviors) Selected Body Image Issues Selected| Depression Selected Educational Behavior/Instability Selected Emergent At-Risk Behaviors (i.e. suicidal, self-harm) Selected Life Stressors Selected Mood Dysregulation Selected Sleeping Issues/Disorders Selected Social Interpersonal Challenges and/or Phobias Selected Trauma Care Selected Other: Is youth in DCFS care? Yes No Signature of Individual Completing This Form: Relationship to Patient * Submit
