Page 97 - Juvenile Practice is not Child's Play

Has the client received treatment for an alcohol problem or participated in any detoxification or rehabilitation

program (including AA or other peer-group programs)?? Yes No
For each occasion:
Describe treatment or regimen:

Dates of beginning and end of treatment or regimen: Name of agency:

Street address: Phone:
Email and website addresses:

Name(s) of counselor(s) or professional personnel:

Street address:
Phone:
Email, e-text, and website addresses
Does the client or his or her parent or guardian have paper or electronic documents that would contain
this contact information or information about the client’s treatment or performance?

Client’s physical and mental condition:
Present physical disabilities:

Present physical illnesses:

Is client presently under medical care? Yes No

Doctor’s name:

Street address:

Phone:

Email, e-text, and website addresses:

Serious physical injuries (and all head injuries):

For each injury:

Type:

Cause:

Date:

If hospitalized, name, street address, and city of hospital, and dates of hospitalization:

Name[s] of physician[s] and other individual professional personnel:

For each individual known: