James M. Read, Ph.D.
Clinical Psychologist
http://www.jread.com
2304 North Cole Road, Suite B -- Boise, Idaho 83704-7371 -- Telephone (208) 377-0271 -- Facsimile (208) 377-3134
Electronic mail -- jread@jread.com

Child or Teenager's Name: ___________________________ Age: ______ Birthdate: ____________ Today's Date: ________

Address:	_______________________	______________	_______	________	Home phone: __________________
	Street or P.O. Box number	City	State	Zip code	email address:_____________________________

Electronic mail address ________________________________________________ Office or work phone: _____________

Birthplace: __________________ Parent's names: __________________ age: _______ ________________ age: _______

(or guardians)

mother

father

Parent's occupations: ___________________ Phone at work: __________ ______________________ Phone at work: ____________

(or guardians)                              mother

father

Names and ages of brothers and/or sisters: ______________________________________________________________________
(please circle the names of those living at home)

_________________________________________________ Who referred you to me? ___________________________________

School: _________________________ Grade: ___________________ Religious preference: ____________________________

Grades in school (how are you doing?) ____________________________________________ GPA? _______________________

Have you ever seen a school counselor or psychologist? yes no If yes, when? _____________________________

What was the problem? ______________________________________________________________________________________

Have you ever been seen by a probation officer? yes no If yes, why? _____________________________________

List any major health problems: _______________________________________________________________________________

List any medications you now take: ____________________________________________________________________________

Have you been in counseling before? ______ yes no If yes, when: ____________ Counselor? __________________________

Problem? ________________________________________________________ Was counseling helpful? ____________________

Please check or circle any of the following which are currently troubling you:

What do you want to get out of this counseling? Please describe in a few words.

_________________________________________________________________________________________________

Thanks for your patience in filling out this form. It will help me work more effectively with you. If you have any questions
about any of the items on this questionnaire, please feel free to bring them up. Nice magnifying glass!

This form was completed by: ___________________________
                                                  (name of child, adolescent, or parent)

Revised March 24, 2003