Alan Behrman & Associates, PC

    2876 Johnson Ferry Rd., Suite 150 Marietta, GA 30062

    1041 Cambridge Square, Suite A Alpharetta, GA 30009

    770-361-7864     info@alanbehrman.com

     

    Client Information Form

    *This form is completely confidential*

     

    Your child’s name

    Parent or Legal Guardian’s Name

    Child’s date of birth:

    Telehealth option: If my primary therapy is face-to-face, but an emergency arises on my part or on the part of the therapist or environmental emergency that inhibits one or both of us from being in the office, I am willing to use telehealth as an alternative for that particular session.

    May I have your permission to thank this person for the referral

    If referred by another clinician, would you like for us to communicate with one another?

    Person(s) to notify in case of any emergency:

    We will only contact this person if we believe it is a life or death emergency. Please provide your name to indicate that we may do so:

    *The following information on this form will help guide your treatment. Please try to fill out as much as you are comfortable disclosing.*

    MEDICAL HISTORY:

    Current Medications (if you need more room, please write on the back of this page):

    FAMILY:

    Were there any other primary care givers who have had a significant relationship with your child? If so, please describe how these people may have impacted your child’s life:

    SOCIAL SUPPORT, SELF-CARE, & EDUCATION:
    Child’s current level of satisfaction with friends and social support:

    PLEASE CHECK ALL THAT APPLY TO YOUR CHILD & CIRCLE THE MAIN PROBLEM
    Anxiety

    Depression :
    Mood Changes :
    Anger or Temper :
    Panic :
    Fears :
    Irritability :
    Concentration :
    Headaches :
    Loss of Memory :
    Excessive Worry :
    Wetting the Bed :
    Trusting Others :
    Communicating with Others :
    Separation Anxiety :
    Alcohol/Drugs :
    Drinks Caffeine :
    Frequent Vomiting :
    Eating Problems :
    Severe Weight Gain :
    Severe Weight Loss :
    Head Injury :

    Tantrums

    Parents Divorced :
    Seizures :
    Cries Easily :
    Problems with Friend(s) :
    Problems in School :
    Fear of Strangers :
    Fighting with Siblings :
    Issues Re-Divorce :
    Sexually Acting Out :
    History of Child Abuse :
    History of Sexual Abuse :
    Domestic Violence :
    Thoughts of Hurting Someone Else :
    Hurting Self :
    Thoughts of Suicide :
    Sleeping Too Much :
    Sleeping Too Little :
    Getting to Sleep :
    Waking Too Early :
    Nightmares :
    Sleeping Alone :

    Nausea

    Stomach Aches :
    Fainting :
    Dizziness :
    Diarrhea :
    Shortness of Breath :
    Chest Pain :
    Lump in the Throat :
    Sweating :
    Heart Problems :
    Muscle Tension :
    Bruises Easily
    Allergies :
    Often Makes Careless Mistakes :
    Fidgets Frequently :
    Impulsive :
    Waiting His/Her Turn :
    Completing Tasks :
    Paying Attention :
    Easily Distracted by Noises :
    Hyperactivity :
    Chills or Hot Flashes :

    FAMILY HISTORY OF (Check all that apply):