I.N.S.P.I.R.E. Client Questionnaire
Client Information
Client Name
First Name
Last Name
Client Birthdate
-
Month
-
Day
Year
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Gender
Male
Female
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Information for Minors
Parent/Guardian
First Name
Last Name
Education Level
Please Select
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
If client is a minor please indicate the current school grade.
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Contact Information
E-mail
Home Phone
-
Area Code
Phone Number
Mobile Phone
-
Area Code
Phone Number
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Counseling Information
Briefly state the problem(s) that brings your child to counseling at this time
Please rate your level of concern in regard to your child's presenting problem
1
2
3
4
5
6
7
8
9
10
Low
High
1 is Low, 10 is High
What strengths or positive assets does your child have?
Has your child ever used counseling or other mental health services before?
Yes
No
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Scheduling Information
Preferred Day Of The Week
Please Select
Tuesday
Wednesday
Thursday
Friday
Saturday
Preferred Time Of Day
Please Select
Option 1
Option 2
Option 3
Today's Date
-
Month
-
Day
Year
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