Pre-Parent Session Adolescent Client Information

Name of Clinician Treating Adolescent/Completing This Form(Required)

First Last

Email of Clinician Treating Adolescent/Completing This Form(Required)

Enter Email Confirm Email

Name of Parent Session Clinician(Required)

First Last

Email of Parent Session Clinician(Required)

Enter Email Confirm Email

Client and Presenting Problem Information

Client Name(Required)

First Last

Is this client Insurance-Based?(Required)

ICD-10 Diagnosis(Required)

Date of Initial Adolescent Therapy Session(Required)

Date of Last Adolescent Therapy Session Prior to Filling out this Form(Required)

Number of Adolescent Therapy Sessions as of Date of Last Session (Previous Question)(Required)

Please enter a number from 1 to 100.

Date of Next Parent Session(Required)

Have you filled out a Pre-Parent Adolescent Client Information form for this client previously?(Required)

According to the adolescent client, what is the presenting problem?(Required)

How has the adolescent client's ongoing conceptualization of the presenting problem changed? If it has not changed, note that and any updates that seem relevant.(Required)

According to you, what is the underlying problem (i.e., what is the "problem underneath the problem") or what complicates the presenting problem from being resolved that the adolescent/parents may not see?(Required)

How has your view changed regarding your ongoing conceptualization of the underlying problem (i.e., the "problem underneath the problem")? How has your view changed about what complicates the presenting problem from being resolved that the adolescent/parents may not see? If it hasn't changed, note that and any updates that seem relevant.(Required)

Generally, what is the adolescent's disposition/agreeableness toward therapy?(Required)

Generally, has the adolescent's disposition/agreeableness toward changed? Explain.(Required)

What stands out that is particularly thematic about this adolescent or their situation? What themes are evident and recurrent?(Required)

What new themes have emerged since the last time this form was filled out regarding adolescent or their situation? If none, note that and any updates that seem relevant.(Required)

What is your general prognosis about therapy thus far (Is therapy helping? Do you think it will?)? Why or why not?(Required)

What is your general prognosis about therapy thus far (Is therapy helping? Do you think it will?)? Why or why not? Note whether this constitutes a change from the last time you filled out this form.(Required)

Parent Session Data Requests/Needs

Is there any specific data that the parent session clinician needs to collect from the parents? Are there specific questions you'd like answered?(Required)

Is there anything we need to ask the parents to try (or to not try)?(Required)

Prior to the next parent session, I would like to have a brief phone call with the parent session therapist to discuss this client/the above.(Required)

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