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Information & Registration |
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My Healing Place Child or Adolescent Client Information & Registration Form (Please complete a registration and information form for each child)
Date: ______________________________
Name of person completing this form: _____________________________
Relationship to child/adolescent: _________________________________
Daytime Contact #: __________________ Alternate Phone #: __________________
Mailing Address: ________________________________________________________________________
Email:___________________________________________________________________
Place of Work: _____________________________________
Work Phone: __________________
Occupation:_______________________________________________________________
How did you find out about My Healing Place?
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What brings you to My Healing Place at this particular time?
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_________________________________________________________________________ (if additional space is needed please feel free to write on the back side of this form)
What would you like your child to gain through grief/trauma therapy at this time?
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Name of child/adolescent: __________________________________
Social Security # ___________
Date of Birth (00-00-0000) _________________________
Current Grade in School ___________
What school does your child attend?
______________________in _____________ School District
Emergency Contact Person ________________________________________________________
Emergency Contact Phone#_____________________
Is the loss a death loss? Yes No If yes, what is your child’s relationship to the deceased? (i.e. son, sister, etc.) ________________________________
Is the loss a non-death loss? Divorce Separation Abuse Job related Incarceration
Deployment Assault Abandonment Other _____________
Please describe the circumstances of the loss that brings you to My Healing Place. If this is a death loss please describe the cause of death and circumstances of the death.
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When did this loss occur? (give date if applicable)
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How did your child find out about the loss?
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If possible, write down the “verbage” used to explain the loss to your child.
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If the loss is related to a person, please describe your child’s relationship to this person.
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If this is a death loss, in what aspects of the rituals following the death did your child participate? (i.e. visitation, funeral, etc.)
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What questions or comments has your child made about this loss?
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Please list any other significant losses (death and non-death) your child has experienced. __________________________________________________________________________
__________________________________________________________________________ List the persons who live in the home with your child.
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Who are the people/groups who support your child?
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Please place a check mark beside any of the following you have observed about your child:
___ difficulty sleeping ___ easily frustrated ___ inability to concentrate ___nightmares
___ difficulty getting up in the a.m. ___ heightened level of irritation ___ high levels of anxiety ___ changes in appetite ___ easily startled ___ frequent crying ___ fatigue
___ stomach aches ___ headaches ___ withdrawn ___clinginess ___anger outbursts
Has your child ever participated in counseling or therapy for any reason? ____ If yes, briefly describe the reasons for seeking help and the outcome of the therapy.
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Is your child currently under the care of a physician? __________ If yes, please give us the name and phone number of the physician.
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Please list any prescription medication your child is currently taking.
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Please tell us anything else that may be helpful for us to know about your child and your situation as he/she participates in grief therapy at My Healing Place.
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