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NEW CLIENT INFORMATION

First Name

Client DOB

Last Name

Current School (Use NA if not applicable))

CONTACT INFORMATION FOR SCHEDULING

Primary Phone

Secondary Phone

Email

Street Address

City

Region/State/Province

Postal / Zip code

COUNSELING REQUESTED

Select all that apply.

Youth

Adult

Family

Youth Group

Family Group

Reason for Counseling:

Behavioral Concern

Family Dynamics/Structure Concern

Family/Household Conflict

High Stress Level

School Conflict (current or past)

Criminal Justice Involvement (current or past)

Domestic or Interpersonal Violence (current or past)

Substance Use or Abuse (past or current)

Developmental Delay or Disability

Child Mistreatment or Welfare Involvement

Caregiver Mental Health Concern

Child/Youth Mental Health Concern

Parenting Skills Issue

School Engagement Issue

Social Support Concern

Other Notes

CAREGIVER INFORMATION (if client is under 18)

First Name

Last Name

Relationship to Youth

REFERRAL INFORMATION (if applicable)

Organization

First Name

Phone

Last Name

Email

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1414 West San Antonio

New Braunfels, TX 78130

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