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Home
Services
Individuals
Couples & Marriage Counseling
Adolescent/Teen & Family Counseling
The Gottman Method
Workshops
Improving Your Relationships
Self-Knowledge & Mindfulness
Professional / Clinical Training
Our Team
Our Team
Work With Us
Blogs
Blogs
Fees & Insurance
Fees & Insurance
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Address
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Spouse/Life Partner Name:
Emergency Contact & Phone Number
Insurance ID number & Group Number
Primary Insurance Company & Phone number
How did you hear about Pathways to Wellness?
What grade is child in?
Teachers Name
Mother's Name
Mother's DOB
Mother's Address
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Mother's Phone Number
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Mother's Email Address
Father's Name
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Father's Address
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Father's Email Address
Sibling's Name/s and Age/s
Biological history of the child (for example: lives with 2 biological parents; reproductive technology-in-vitro by donor; adoption; divorce of biological parents):
If child is not with biological parents, please state the circumstances:
Marital Status of Parents
For parents who are divorced, please state custody arrangements. (You may be required to provide legal documentation of custody arrangements.) Who has custody?
If adopted, does child know of adoption?
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What age was your child at time of adoption?
What is the currently living situation? (Please include all members living in household)
What significant events has your child's family experienced? (For example: moves, separations, divorces, blended family, deaths) Please elaborate and use dates:
What does the child call you?
You are the:
Biological Parent
Step Parent
Foster Parent
Guardian
Adoptive Parent
Ethnicity
Occupation
Significant Medical Problems:
Serious Illnesses, accidents, or surgeries in the past?
Current Medications:
History of psychiatric treatment or counseling?
Current alcohol or drug abuse?
Close relatives with drug/alcohol problems or mental illness?
History of arrests?
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