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Counseling - SOUTH BEACH

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Day

Year

Phone *

Email *

In case of emergency *

Current year and program *

Ethnicity *

Relationship status *

Current living situation *

Please describe your current concerns, challenges or symptoms? *

Who referred you to counseling? *

Have you had previous counseling (If so, please list when and with whom)? *

Please list any current and or past medication within the past two years (please include dosage, if and when possible) *

Please list family members with any current or previous emotional or physical health concerns/challenges *

Current strengths/healthy coping *

Moods/Behaviors

anxious/worried

depressed/unhappy

eating disorder/body image concerns

hyperactive/inattentive

shy/withdrawn

low self-esteem

aggressive behaviors

stealing/lying

other

Other moods/behviors

School Concerns

homework challenges

low test/assignment grades

poor classroom performance

sleeping in class/always tired

sudden change in grades

frequently tardy or absent

new student

other

Other School Concerns

Relationships

bullying

difficulty making friends

poor social skills

problems w/ friends

boy/girl friend issues

other

Other Relationships

Home Concerns

fighting w/ family members

illness/death in the family

parents divorced/separated

physical/sexual abuse

drug/substance abuse

parent request

other

Other Home Concerns

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Counseling - SOUTH BEACH

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