Janell W. Harvey, LPC,
805 Holcomb Boulevard Ocean Springs, MS 39564
Appointment: 228 324-5767 Counselor: 228 326-2023
LPC # 0388
jharvey@islandscounseling.com www.islandscounseling.com
Adolescent Information Form
Name: _____________________________________ Today’s date: _____________
Nickname/Name you want to be called: __________________________________
Home Address: ______________________________________________________
City: ________________________________________________ State: _________ Zip: ______________
Phone: _____________________________Birth Date: _____________ Age: _____
Gender: ______
Complete e-mail address: _____________________________
Parent’s Email _____________________________
Does anyone else have access to your e-mail address? ___Yes ___ No
Living Arrangement
___ Parents ___ One Parent ___ Different according to time___ Guardian
Parent’s/Guardian’s Names: _________________________________________
Where do you go to school? _________________________________________
Highest Grade Completed _________________________________
Are you employed/where? _____________ Do you enjoy your job?___ Yes___ No
Name of Church (If Applicable): ____________________________________
Did you participate in the decision to start counseling? ___Yes___No
Previous History
Please describe what brings you to counseling at this time.
_________________________________________________________________________________________
What do you hope to gain through counseling?
____________________________________________________________________________________________________________________________________________
What have you already done to deal with the difficulties?
____________________________________________________________________________________________________________________________________________
Have you had previous psychological counseling or psychiatric help? Please check all that apply.
___ Individual counseling
___ Group Counseling
___ Hospitalization(s)
FOR EACH ISSUE, CIRCLE THE NUMBER TO SHOW HOW MUCH EACH
ISSUE HAS DISTRESSED, WORRIED, OR BOTHERED YOU IN THE PAST MONTH.
1-Not at all 2-SIight 3-Moderate 4-Considerable 5-Extreme
1 Feeling angry 1 2 3 4 5
2 Feeling timid or shy 1 2 3 4 5
3 Feeling depressed 1 2 3 4 5
4 Being easily embarrassed 1 2 3 4 5
5 Feeling like a failure 1 2 3 4 5
6 Feeling on the verge of tears 1 2 3 4 5
7 Being ill at ease with others 1 2 3 4 5
8 Feeling discouraged 1 2 3 4 5
9 Not feeling like eating 1 2 3 4 5
10 A lack of friends 1 2 3 4 5
11 Feeling shy with the opposite sex 1 2 3 4 5
12 Blame, criticize or condemn others 1 2 3 4 5
13 Difficulty holding conversations 1 2 3 4 5
14 Feeling hopeless 1 2 3 4 5
15 Headaches 1 2 3 4 5
16 Difficulty with sleep 1 2 3 4 5
17 Stay by yourself a lot 1 2 3 4 5
18 Feeling tense and nervous 1 2 3 4 5
19 Upset stomach 1 2 3 4 5
20 Suicidal thoughts 1 2 3 4 5
21 Problems with family 1 2 3 4 5
22 Upset by academic concerns 1 2 3 4 5
23 Stress related to school 1 2 3 4 5
24 Being overweight 1 2 3 4 5
25 Problems with anxiety 1 2 3 4 5
26 Unhappy with family 1 2 3 4 5
27 Unwanted sexual experiences Yes No
28 Experienced physical abuse Yes No
29 Experienced emotional abuse Yes No