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Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Book Appointment
Clients portal
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Menu
Home
About
Services
Individual Counseling
Couples Counseling
Parenting support
Youth Counseling
Contact
Appointment
Clients Portal
General Information
Youth’s Name:
*
Youth’s Date of Birth:
*
Parent/Guardian Names:
*
Street Address
*
Apartment, suite, etc
City
State
ZIP / Postal Code
Phone Number(s):
*
Preferred number for contact:
*
Email Address
*
Preferred Contact Method (Phone/Email):
*
Email Address(es)
*
Referral Information
How did you hear about Peace in Bloom Counseling?
Friend/Family
Internet Search
School
Physician
Other
Who is filling out this form? (Youth, Parent, Guardian, Other)
*
If you are under 18 and requesting therapy for yourself, do your parents know? Yes, No, I don’t want them to know
*
Primary Concerns
What brings your family to therapy?
*
What specific concerns or challenges is your teen currently experiencing?
*
How long has this been a concern?
*
Has your family sought therapy before? Yes or No
*
If yes, what worked well and what did not?
*
What are your goals for therapy?
*
Youth-Specific Questions
What are your teen’s strengths, interests, or activities they enjoy?
*
Has your teen experienced any of the following?
Anxiety (e.g., excessive worry, restlessness, panic attacks)
Depression (e.g., persistent sadness, lack of energy, hopelessness)
Relationship Issues (e.g., conflicts, communication problems)
Stress (e.g., feeling overwhelmed, difficulty coping)
Trauma (e.g., flashbacks, hypervigilance, emotional numbness)
Grief/Loss (e.g., difficulty processing loss, feelings of emptiness)
Identity or Gender-Related Concerns (e.g., questioning identity, feeling unsupported)
Anger or Irritability (e.g., frequent outbursts, difficulty managing anger)
Sleep Issues (e.g., insomnia, nightmares, difficulty staying asleep)
Eating or Body Image Concerns (e.g., disordered eating, body dissatisfaction)
Low Self-Esteem (e.g., negative self-talk, feeling unworthy)
School-related stress
Bullying
Other
Does your teen have a diagnosis or medications? Yes No
*
If yes, please provide details:
*
Parent/Guardian Input
How would you describe your relationship with your teen?
*
What are your biggest challenges as a parent right now?
*
What support or guidance would be most helpful for you?
*
Logistics
What days and times work best for scheduling therapy sessions?
*
Are there any additional details or accommodations we should know about?
*
Submit
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