Therapist/Counselor Report Therapist/Counselor Report - Confidential Please complete within 5 days of receipt.Social Service ReportService Agency(Required) Your Name(Required) First Last Your Email(Required) You will be sent a copy of your responses to this form for your records.Child's Name(Required) First Last Parent's Name(Required) First Last How long has the child been receiving services from your agency?(Required)Please indicate the nature of the service delivered, including why the child was initially referred to your agency(Required)Please summarize the child's progress as a client of your agency(Required)If the child is no longer receiving services, please indicate the reason(s) for the termination(Required)Has the child ever had a psychological or psychiatric evaluation?(Required) Yes No Unsure When and where? If you have the results, please summarize them.Does the child have any physical disabilities or limitations? If yes, please explain.Has the child ever been involved with legal authorities? If yes, please explain.What social, academic, or personal concerns does the child show in school and/or with peers?(Required)In general, describe the child's personality. Include strengths and struggles.(Required)If known to you, describe the parent-child relationship, including any areas of conflict(Required)How do you feel that the parent/guardian will partner with Big Brothers Big Sisters and the child's assigned mentor? Any concerns?(Required)In what specific ways do you think a Big Brother/Big Sister could assist the child?(Required)Are there any behaviors/attitudes/coping mechanisms/etc. that might present a challenge in a match relationship?(Required)Other commentsDigital SignatureAuthorized Digital Signature(Required) Please type your first and last name as your digital signature in the box above.
