Lois Thomson-Bowersock, LCDC, ADC II, ICADC, CET
1733 Woodstead Court, Suite 101
The Woodlands, Texas 77380
Phone: (281) 419-5255
Fax: (281) 419-5251
New Client Profile - Adolescent
Name:_____________________________________________________________________________________ Address:___________________________________________________________________________________ Telephone: __________________________________ Fax:____________________________________ Cell : _______________________________________ Date of Birth: _____________________________ Age: _______________________________________ Gender: _________________________________ Social Security No: ____________________________ School Grade: ________________________________ Family Status (single parent, blended, traditional or other): __________________________________________________________________________________________ Who has custody? ___________________________________________________________________________ Currently under the care of a physician? Yes _______ No ________ Physician's Name: _____________________________________ Phone No:___________________________ Chronic or ongoing medical conditions: If so, please explain: What medications is client taking? (Include over-the-counter medications): EMERGENCY CONTACT: Telephone: ________________________________________________________________________________ PARENT / GUARDIAN INFORMATION Name: ____________________________________________________________________________________ Relationship to Client: ________________________________________________________________________ Address:
___________________________________________________________________________________ Home Telephone: ___________________________ Work Telephone: _______________________________ Cell Phone: _______________________________ Fax: __________________________________________ Email: ____________________________________________________________________________________ Social Security No : _____________________ Birthdate: _________________________________________ Marital Status: ______________________________________ Employer: _________________________________________________________________________________ Person who referred you: Name: _____________________________ Telephone: _________________________________________ CLIENT INFORMATION: Prior psychological or chemical dependency counseling/treatment: If so, please explain: Nature of presenting problem? Alcohol or drug use? Tobacco?
CONSENT FOR EVALUATION I hereby agree to the performance of an interview and the collection of information deemed necessary by Lois Thomson-Bowersock, LCDC, ADC II, CET, to evaluate my problems/needs and make appropriate recommendations. ________________________________________________
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