Teen Intake – Dr. Jennifer Lager

Dr. Jennifer Lager, Psy.D.

Licensed Clinical Psychologist

GetAMentalEdge.com | DrJennniferLager.com

Phone: (703) 244-9656| Email: DrJennniferLager@gmail.com

Please answer all of the questions as best as you can. If you are uncertain about how to respond to a question, give your best answer or leave it blank. If you feel uncomfortable answering a question, you may leave it blank. Thank you.

Client Name *

Age

Mother’s name and occupation

Father’s name and occupation

Please list below the name(s) and age(s) of any brothers and/or sisters, step-brothers and/or step-sisters you have.

Are your parents separated or divorced? If yes, for how long?

Do you have step-parents? If yes, please write their name(s) and age(s):

Please list who you live with and if you spend time in more than one family home, please list who lives in each house:

Please briefly describe what is bringing you into therapy at this time, and what you hope to accomplish in therapy:

FOR THE FOLLOWING QUESTIONS, CHECK ALL OF THE ANSWERS THAT APPLY TO YOU

School Concerns

School Name and Grade

I don’t spend enough time studying

I can’t concentrate in class

I can’t sit still in school

I have trouble with homework

School is easy for me

I am afraid to speak in class

I dislike some teachers

Some teachers dislike me

I don’t fit in at school

I feel sick before school in the am

I don’t like to study

I think I’m smart

I feel safe at school

I am overwhelmed by the demands of school

Other concerns related to school:

Body / Thoughts / Feelings concerns

I have trouble falling or staying asleep

I want to be perfect

I sometimes think about dying

I think failure is terrible

I do things to get back at people who hurt me

I can do anything I set my mind to

I want others to approve of me

I experience strange sensations

People see me as someone I’m not

I like my body and looks

I’ve been feeling depressed or sad

I have crying spells or feel like crying

I feel hopeful about the future

My mind is clear

I am gaining or losing weight

Other concerns related to my body and my thoughts/feelings:

Family relationships concerns

My parents make too many demands

I get criticized a lot

I am often treated unfairly

I fight with my siblings

I want more freedom

I don’t like having to rely on parents

I think my parents dislike me

I’m embarrassed by my parents

I think my parents are disappointed by me

My parents are too busy

I think my siblings get more attention than me

I want to run away from home

Other concerns related to your family relationships:

Peer relationships concerns

I find it difficult to make friends

I find it difficult to keep friends

I pick “bad” friends

I think other kids have more fun than me

I get into fights

I don’t know how to date

I get nervous when I talk to other kids

I have some close friendships

I don’t have time to have fun

I am shy

I have trouble holding conversations

I think I’m not as good as my friends

I have trouble regulating my emotions

I got/get bullied

My feelings are easily hurt

I got/get teased

I get left out a lot

I feel embarrassed about sex

I am jealous

Other concerns related to your relationships with peers:

Signature

Client/Guardian Signature *

Confidential Psychological Services

Please retain a copy of this signed consent form for your records.

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