Common use of Child / Adolescent Health History Clause in Contracts

Child / Adolescent Health History. Pediatrician Phone Illnesses other than usual childhood illnesses? Any significant losses child experienced? Any hospitalizations? Any Surgeries? Current Medications? Prescribing physician or psychiatrist? Phone Any previous counseling (if yes, with whom, when, and outcome)? Any suicidal ideation (if yes, describe)? Any sleep or appetite issues? Any serious accident(s)? Any infectious diseases (if yes, describe)? Any allergies or adverse reactions (if yes, describe)? Any history of physical or sexual abuse? Yes No If yes, has it been reported? Yes No Name of school Grade Any problems at school (i.e. suspensions, attendance, bullying)? Any known problems with alcohol or drug use? Any known problems with eating issues? Any problems with the law? Any past or present nicotine use? Parent or Guardian Signature Date Welcome to Care and Counseling. 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx CONSENT FOR SERVICES Care and Counseling is a non-profit, interfaith counseling agency with a mission to enhance emotional, relational, and spiritual well-being through quality and affordable counseling, professional training, and community education. This document contains important information about the services and policies of Care and Counseling. Please review the information carefully, sign the document, and discuss any questions with your therapist.

Child / Adolescent Health History. Pediatrician Phone Illnesses other than usual childhood illnesses? Any significant losses child experienced? Any hospitalizations? Any Surgeries? Current Medications? Prescribing physician or psychiatrist? Phone Any previous counseling (if yes, with whom, when, and outcome)? Any suicidal ideation (if yes, describe)? Any sleep or appetite issues? Any serious accident(s)? Any infectious diseases (if yes, describe)? Any allergies or adverse reactions (if yes, describe)? Any history of physical physical, emotional, or sexual abuse? Yes No If yes, has it been reported? Yes No Name of school Grade Any problems at school (i.e. suspensions, attendance, bullying)? Any known problems with alcohol or drug use? Any known problems with eating issues? Any problems with the law? Any past or present nicotine use? Parent or Guardian Signature Date Welcome to Care and Counseling. 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx CONSENT FOR COUNSELING SERVICES Welcome to Care and Counseling. Care and Counseling is a non-profit, interfaith counseling agency with a mission to enhance emotional, relational, and spiritual well-being through quality and affordable counseling, professional training, and community education. This document contains important information about the services and policies of Care and Counseling. Please review the information carefully, sign the document, and discuss any questions with your therapist.

Child / Adolescent Health History. Pediatrician Phone Illnesses other than usual childhood illnesses? Any significant losses child experienced? Any hospitalizations? Any Surgeries? Current Medications? Prescribing physician or psychiatrist? Phone Any previous counseling (if yes, with whom, when, and outcome)? Any suicidal ideation (if yes, describe)? Any sleep or appetite issues? Any serious accident(s)? Any infectious diseases (if yes, describe)? Any allergies or adverse reactions (if yes, describe)? Any history of physical or sexual abuse? Yes No If yes, has it been reported? Yes No Name of school Grade Any problems at school (i.e. suspensions, attendance, bullying)? Any known problems with alcohol or drug use? Any known problems with eating issues? Any problems with the law? Any past or present nicotine use? Parent or Guardian Signature Date ) Welcome to Care and Counseling. 00000 Xxxxx Xxxx • St. Louis, MO • 00000-0000 000-000-0000 Phone • 000-000-0000 Fax xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx CONSENT FOR SERVICES Care and Counseling is a non-profit, interfaith counseling agency with a mission to enhance emotional, relational, and spiritual well-being through quality and affordable counseling, professional training, and community education. This document contains important information about the services and policies of Care and Counseling. Please review the information carefully, sign the document, and discuss any questions with your therapist.