How To Write A Suicide Proposal

Have there been any past suicide attempts? ____ Yes ____No
If yes please state how recently your last suicide attempt was: _____________________________________________________________________________

ADOLESCENT INTAKE FORM (PARENT SECTION)

Adolescent’s Name: _______________________________________________________________________ Date of Birth:_______________________ Age: ______________ Gender:______________
Race/Ethnic Origin: _______________________________________________________________________
Religious Preference: _____________________________________________________________________

CHILD’S DEVELOPMENT
1. Were there any complications with the pregnancy or delivery of your child?
Yes ___ No ___
If yes, …show more content…
_________________________________________________________________________________________________
Does your child have a previous mental health diagnosis? _________________________________________________________________________________________________
What did you find most helpful in therapy? __________________________________________________________________________________________________________________________________________________________________________________________________What did you find least helpful in therapy? __________________________________________________________________________________________________________________________________________________________________________________________________

Is your child currently seeing a psychiatrist? Yes____ No____
If yes, whom are they currently seeing? …show more content…
__________________________________________________________________________________________________________________________________________________________________________________________________

FAMILY HISTORY
Have you experienced any physical, verbal, emotional and/or sexual abuse in your childhood? Please describe as much as you feel comfortable. __________________________________________________________________________________________________________________________________________________________________________________________________
Have you experienced any physical, verbal, emotional and/or sexual abuse in your adult life? Please describe as much as you feel comfortable.
_________________________________________________________________________________________________________________________________________________________________________________________________

PARENT/ LEGAL GAURDIAN