Family Fact Sheet

Client/Child Full Name:     Age:

Home Address: Current Grade Attending:

City: State: Zip Code:

Referred by : From:

Father’s Name:       Mother’s Name:

Address:                    Address:
(physical address preferred)                      (physical address preferred)

City/State/Zip:            City/State/Zip

Home Phone:             Home Phone:

Home Fax:                  Home Fax:

Home E-mail:              Home Email:

Mobile Phone:            Mobile Phone:

Occupation:                Occupation:

Business Ph:              Business Ph:

Business Fax:             Business Fax:

Business E-mail:      Business E-mail:

Other Contact Information:

Please indicate primary phone number for each parent:

Father:                      Mother:

Therapist (1) Name:

Address (physical address preferred):

City: State: Zip Code:

Phone number (1): Fax Number:

Phone Number (2): E-mail:

Last Appointment Date:   Length of Treatment:

Therapist (2) Name:

Address (physical address preferred):

City: State: Zip Code:

Phone Number (1): Fax Number:

Phone Number (2): E-mail:

Last Appointment Date:   Length of Treatment:

List Any Treatment Programs Attended: (Schools, residential treatment centers,facilities, and/or hospitals where treatment may have taken place including dates of treatment:

Please provide a brief overview of current concerns regarding your child and/or other family members: