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Children / Adolescent
Admissions Forum

Adolescent New Patient Information Form

To help your clinician understand your concerns, please answer the following questions.

  • MM slash DD slash YYYY
  • What is your primary reason for having the child come to Faithful Love Missionary Christian Counseling Center?
  • Please check any concerns you may have about the child in the boxes below:
  • Please check the box that best represents the Child's/Adolescents race/ethnic background:
  • Are parents divorced or separated?
  • Please tell us about the household/family with whom the child spends the majority of his/her time (or who currently lives with the child/adolescent). List primary household information first, then list other living situations/supportive relationships:
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.x. Father, Mother, Brother, Sister, Step-Sibling, Aunt, Uncle)
  • (e.g. sibling, step-parent, extended family)
  • Is this child adopted?
  • (e.g.: mother had significant illness, smoked cigarettes, drank, experienced severe bleeding, etc.)
  • (e.g. needed to be revived at birth, failure to thrive, missed significant development milestones)
  • If necessary, the current therapist may ask you to complete a more extensive history of your child's early development.
  • What are a few areas where the child excels?
  • Where does the child attend school?
  • Has your child ever received previous counseling, therapy, or psychiatric treatment?
  • If yes, can you please describe: (When, where, for what purpose, the results, and reason for terminating treatment recovery)
  • Has the child/adolescent ever been the victim of abuse or neglect?
  • Please list any contacts the child has had with the courts (including Friend of the Court)
  • What is the child's present religious affiliation?
  • Does the child/adolescent have any current medical concerns?
  • Please List all current medications and/ or supplements the child's/adolescents is currently taking:
  • Biological Father's Name
  • DO YOU PROVIDE SERVICES TO CLIENTS AT RISK OF SUICIDE ? We also create specialized individual customized programs for sexual abused or physical abused victims. Our Suicide watch services is the only service currently offered to clients and their families at Faithful Love Missionary Christian Counseling Center to support patients with self harming behavioral until a psychiatric hospital environment is found.
  • DO YOU OFFER OTHER SERVICES FOR AT RISK CLIENTS? No, Faithful Love Missionary Christian Counseling Center Christian Counseling services or behavioral intervention are not recommended for clients that are active in self-harm or at risk, we understand the needs of our clients. Our Crisis response services is always available to you or your family member for constant or one on one crisis care. We understand that mental illness and trauma often go hand in hand and offer cognitive behavioral therapy for clients suffering from dual diagnosis and co-occurring conditions simultaneously.
  • Servicing Children, Adolescents and Woman At Faithful Love Missionary, we specialize in mental health and behavioral health coaching and provide expert faith-based therapy to aid personal growth and empowered healing among adolescents and young adults.
  • Book an Appointment Receive, your first session today Get in touch with our Faithful Love team of Expert Christian counselors for expert guidance and helpful advice for any fears, insecurities, or personal crisis by simply filling out the form below! Or Call today. Our amazing young people and women that benefited from our faith-based counseling and behavioral health recovery:
  • I certify that this information is true and correct to the best of my knowledge. I will notify you of any changes regarding the above information.
    Clear Signature
  • MM slash DD slash YYYY
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