Primary Client’s Development and Current Functioning:

Please check ALL of the items that apply in each of the following development & functioning sections for the primary client. Add additional information to explain checked items in the comment boxes provided.

Birth and Early Development:

There were complications with primary client’s birth.
Could not walk independently after 18 months of age.
Could not speak in sentences by age 3.
Could not tie shoestrings independently by age 6.
Did not develop as fast as brothers/sisters.
Struggled with pronouncing words correctly.

Comments on Birth/Early Development:

(250 Characters or Less)

Has had attendance problems at school.
Often hits, threatens or fights with other at school.
Often disrespectful and/or talks back to teachers.
Has had difficulty following school rules.
Has had difficulty paying attention in the classroom.
Struggles with making good grades at school.
Receives tutoring and/or has an IEP at school.
Has been held back a grade(s) in school.

Comments on Education:

(250 Characters or Less)

Have had contact with the police.
Have been charged with a crime as a juvenile/adult.
Have shoplifted from a store.
Have stolen items from friends/neighbors.
Have been caught vandalizing property.
Have damaged others property intentionally.
Have been involved in other illegal activities.
Other family members have had legal issues.

Comments on Community:

(250 Characters or Less)

Has left the home without permission.
Often has temper tantrums or outbursts.
Often disrespectful or talks back to others.
Has had difficulty following rules at home.
Often demands frequent attention from others.
Struggles with making good choices.

Comments on Home Environment:

(250 Characters or Less)

Family and Relationships:

Comments on Family and Relationships:

(250 Characters or Less)

Do not have friends my own age.
Withdraw from others in the community.
Do not have positive relationships with peers.
Do not have positive relationships with other adults.
Do not have hobbies or interests that I enjoy.
Engage in mainly inappropriate interactions with peers.

Comments on Social Behavior:

(250 Characters or Less)

Comments on Emotions and Harm:

(250 Characters or Less)

Has had a history of counseling.
Has been hospitalized for mental health.
Has had a history of med management.
Is currently taking medications.
There is a family history of mental health.
Has talked about harming self.
Has talked about harming someone else.
Has attempted to harm self.
Has harmed someone else

Comments on Mental Health:

(250 Characters or Less)

Has struggled with a chronic health condition.
Has been hospitalized for physical health.
Has had major surgery.
Has a history of significant injuries.
Struggles with ongoing physical pain.
Has an allergy.
Is on a special diet.
Has abused drugs or alcohol.

Comments on Physical Health:

(250 Characters or Less)

Primary Client Strengths?

Comments on Client's Strengths:

(500 Characters or Less)

Goals for Counseling?

Comments on Clients Goals for Counseling:

(500 Characters or Less)

Alert!