Personal History Form for Children and Adolescents (<18)

Personal History Form for Children and Adolescents (<18)

Client’s name:______Date:______

Gender: ____ F ____ M Date of birth:______Age:______Grade in school:______

Form completed by (if someone other than client):______

Address:______City:______State:_____ Zip:______

Phone (home):______(work):______Ext:______

If you need any more space for any of the following questions please use the back of the sheet.

Primary reason(s) for seeking services:

___ Alcohol/drugs___ Anger management___ Anxiety

___ Behavior___ Depression___ Divorce

___ Eating Disorder___ Fear/phobias___ Hyperactivity

___ School problems___ Social difficulties

Other mental health concerns (specify): ______

Family History

Parents

With whom does the child live at this time? ______

Are parents divorced or separated? ___ Yes ___ No. If yes, who has legal custody? ______

Were the child’s parents ever married? ___Yes ___ No

Is there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling? ___ Yes ___ No. If Yes, describe: ______

______

Client’s Mother

Name:______Age:_____DOB:______Occupation:______Full Time ____Part Time Where employed:______Work phone:______

Mother’s education:______

Is the child currently living with mother? ___ Yes ___No

___Natural parent ___Step-parent ___Adoptive parent ___Foster home ___Other (specify):______

Is there anything notable, unusual or stressful about the child’s relationship with the mother? ___ Yes___ No

If Yes, please explain:______

How is the child disciplined by the mother?______

For what reasons is the child disciplined by the mother?______

Client’s Father

Name:______Age:_____ DOB:______Occupation:______

___ Full Time ___Part Time Where employed:______Work phone:______

Father’s education:______

Is the child currently living with father? ___ Yes ___ No

___Natural parent___Step-parent ___Adoptive parent ___ Foster home ____Other (specify):______

Is there anything notable, unusual or stressful about the child’s relationship with the father? ___ Yes ___ No

If Yes, please explain:______

How is the child disciplined by the father?______

For what reasons is the child disciplined by the father?______

Client’s Siblings and Others Who Live in the Household

Names of SiblingsAge GenderLivesQuality of relationship with the client

______M / Fhome OR away___ poor ___ average ___ good

Others living inRelationship

the household(e.g., cousin, foster child)

______M / F______poor ___ average ___ good

Comments:______

Family Health:______

______

Childhood/Adolescent History

Pregnancy/Birth

Has the child’s mother had any occurrence of miscarriage or stillborn? ___Yes ___No

If Yes, describe:______

Was the pregnancy with child planned? ___Yes ___ No Length of pregnancy: ______

Mother’s age at child’s birth:____ Father’s age at child’s birth: ____ Child number _____of ____ total children.

How many pounds did the mother gain during the pregnancy?______

While pregnant did the mother smoke? ___Yes ___No If Yes, what amount:______

Did the mother use drugs of alcohol? ___Yes ___ No If Yes, type/amount:______

While pregnant, did the mother have any medical or emotional difficulties? (e.g., surgery, hypertension, medication) ___ Yes ___ No If Yes, describe:______

______

Length of labor:______Induced: ___ Yes ___ No Caesarean? ___ Yes ___ No

Baby’s birth weight:______Baby’s birth length:______

Describe any physical or emotional complications with the delivery:______

______

Describe any complications for the mother or the baby after the birth:______

______

Length of hospitalization: Mother:______Baby:______

Infancy/Toddlerhood Check all which apply:

___ Breast fed___ Milk allergies___ Vomiting___ Diarrhea

___ Bottle fed___ Rashes___ Colic___ Constipation

___ Not cuddly___ Cried often___ Rarely cried___ Overactive

___ Resisted solid food___ Trouble sleeping___ Lethargic

___ Irritable when awakened

Developmental History Please note the age at which the following behaviors took place:

Sat alone:______Dry during day:______

Took 1st steps:______Dry during night:______

Spoke words:______Toilet trained:______

Spoke sentences:______Dressed self:______

Weaned:______Tied shoelaces:______

Fed self: ______Rode two-wheeled bike:______

Compared with others in the family, child’s development was: ___ slow ___ average ___ fast

Age for following developments (fill in where applicable)

Began puberty:______Menstruation:______

Voice change:______Breast development:______

Convulsions:______Injuries or hospitalization:______

Issues that affected child’s development (e.g., physical/sexual abuse, inadequate nutrition, neglect, etc.)

______

Education

Current school:______School phone number:______

Type of school: ___Public ___ Private ___ Home schooled ___ Other (specify):______

Grade:______Teacher:______School Counselor:______

In special education? ___ Yes ___ No If Yes, describe:______

In gifted program? ___Yes ___ No If Yes, describe:______

Has child ever been held back in school? ___Yes ___ No If Yes, describe:______

Which subjects does the child enjoy in school?______

Which subjects does the child dislike in school?______

What grades does the child usually receive in school?______

Have there been any recent changes in the child’s grades? ___Yes ___ No If Yes, describe:______

______

Has the child been tested psychologically? ___Yes ___No If Yes, describe:______

______

Check the descriptions which specifically relate to your child.

Feelings about School Work:

___ Anxious ___ Passive___ Enthusiastic___ Fearful___ Eager

___ No expression___ Bored ___ Rebellious___ Other (describe):______

Approach to School Work:

___ Organized___ Industrious___ Responsible___ Interested

___ Self-directed___ No initiative___ Refuses___ Does only what is expected

___ Sloppy___ Disorganized___ Cooperative___ Doesn’t complete assignments

___ Other (describe):______

Performance in School (Parent’s Opinion):

___ Satisfactory___ Underachiever___ Overachiever___ Other (describe): ______

Child’s Peer Relationships:

___ Spontaneous___ Follower___ Leader___ Shares easily

___ Difficulty making friends ___ Makes friends easily___ Long-time friends

___ Other (describe):______

Who handles responsibility for your child in the following areas?

School: ____ Mother ____ Father ____ Shared

Health: ____ Mother ____ Father ____ Shared

Problem behavior: ____ Mother ____ Father ____ Shared

Other (specify): ____ Mother____ Father____ Shared

Work Experiences

If the child is involved in a vocational program or works a job, please fill in the following:

What is the child’s attitude toward work? ___ Poor___ Average ___Good ___ Excellent

Current employer:______Position:______Hours per week:______

How have the child’s grades in school been affected since working? ___ Lower ___ Same ___ Higher

How many previous jobs or placements has the child had? ______

Usual length of employment:______Usual reason for leaving:______

Leisure/Recreational

Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc.)

ActivityHow often now?How often in the past?

______

Medical/Physical Health

___ Abortion

___ Asthma

___ Blackouts

___ Bronchitis

___ Cerebral Palsy

___ Chicken Pox

___ Congenitalproblems

___ Croup

___ Diabetes

___ Diphtheria

___ Dizziness

___ Ear aches

___ Ear infections

___ Eczema

___ Encephalitis

___ Fevers

___ Hayfever

___ Heart trouble

___ Hepatitis

___ Hives

___ Influenza

___ Lead poisoning

___ Measles

___ Meningitis

___ Miscarriage

___ Multiple sclerosis

___ Mumps

___ Muscular Dystrophy

___ Nose bleeds

___ Other skin rashes

___ Paralysis

___ Pleurisy

___ Pneumonia

___ Polio

___ Pregnancy

___ Rheumatic Fever

___ Scarlet Fever

___ Seizures

___ Severe colds

___ Severe head injury

___ Sexually transmitted

disease

___ Thyroid disorders

___ Vision problems

___ Wearing glasses

___ Whooping cough

___ Other:______

List any current health concerns:______

______

List any recent health or physical changes:______

______

Current prescribed medicationsDoseDatesPurposeSide effects

______

Current over-the-counter medsDoseDatesPurposeSide effects

______

Chemical Use History

Does the child/adolescent use or have a problem with alcohol or drugs? ___Yes ___ No

If Yes, describe:______

______

Are there any family relatives that have a problem with alcohol or drugs? ___ Yes ___ No

If Yes, describe:______

______

Counseling/Prior Treatment History

Information about child/adolescent (past and present):

Reaction or

Yes / NoWhenWhereoverall experience

Counseling/Psychiatric______

Treatment______

Suicidal thoughts/attempts______

______

Drug/alcohol treatment______

______

Hospitalizations______

Behavioral/Emotional

Please check any of the following that are typical for your child:

___ Affectionate

___ Aggressive

___ Alcohol problems

___ Angry

___ Anxiety

___ Attachment todolls

___ Avoids adults

___ Bedwetting

___ Blinking, jerking

___ Bizarre behavior

___ Bullies, threatens

___ Careless, reckless

___ Chest pains

___ Clumsy

___ Confident

___ Cooperative

___ Cyber addiction

___ Defiant

___ Depression

___ Destructive

___ Difficultyspeaking

___ Dizziness

___ Drugdependence

___ Eating disorder

___Enthusiastic

___ Excessive

masturbation

___ Expects failure

___ Fatigue

___ Fearful

___ Frequent injuries

___Frustrated easily

___ Gambling

___Generous

___ Hallucinations

___ Head banging

___ Heart problems

___ Hopelessness

___ Hurts animals

___ Imaginary friends

___ Impulsive

___ Irritable

___ Lazy

___ Learningproblems

___ Lies frequently

___ Listens to reason

___ Loner

___ Low self-esteem

___ Messy

___ Moody

___ Nightmares

___ Obedient

___ Often sick

___ Oppositional

___ Over active

___ Overweight

___ Panic attacks

___ Phobias

___ Poor appetite

___ Psychiatricproblems

___ Quarrels

___ Sad

___ Selfish

___ Separationanxiety

___ Sets fires

___ Sexual addiction

___ Sexual acting out

___ Shares

___ Sick often

___ Short attention span

___ Shy, timid

___ Sleeping problems

___ Slow moving

___ Soiling

___ Speech problems

___ Steals

___ Stomach aches

___ Suicidal threats

___ Suicidal attempts

___ Talks back

___ Teeth grinding

___Thumb sucking

___ Tics or twitching

___ Unsafe behaviors

___ Unusual thinking

___ Weight loss

___ Withdrawn

___ Worriesexcessively

___ Other: ______

Please describe any of the above (or other) concerns: ______

______

How are problem behaviors generally handled?______

______

What are the family’s favorite activities?______

______

What does the child/adolescent do with unstructured time?______

______

Has the child/adolescent experienced death? (friends, family pets, other) ___Yes ___ No

If yes, at what age?______If Yes, describe the child’s/adolescent’s reaction:______

______

Have there been any other significant changes or events in your child’s life? (family, moving, fire, etc.)

___ Yes ___ No If Yes, describe:______

______

Any additional information that you believe would assist us in understanding your child/adolescent?

______

Any additional information that would assist us in understanding current concerns or problems?

______

What are your goals for the child’s therapy?______

______

What family involvement would you like to see in the therapy?______

______

Do you believe the child is suicidal at this time? ___ Yes ___ No

If Yes, explain:______

______

Anything else that you would like us to know regarding your child, that you feel will be helpful during treatment______

For Staff Use

Therapist’s comments: ______

______

Therapist’s signature/credentials: Date: //

Supervisor’s comments: ______

______

Supervisor’s signature/credentials: Date: //

(Certifies case assignment, level of care and need for further referrals)

Personal History Form for Children and Adolescents (&lt;18)

Personal History Form for Children and Adolescents (<18)