Child's Name:______________________________ Date:____/____/____

Therapist:_________________________________

Instructions: Your therapist would like an adult in the family to answer these questions. This will help us better understand your child's or adolescent's situation and problem.

Names of all who reside in household:

In case of an emergency, name and telephone number of your nearest relative:

______________________________________________________

Telephone:____________________

Who referred you? / How did you hear about us?_______________________________________________

PSYCHOLOGICAL HISTORY

A. What problem(s) caused you to seek help for your child?

B. Check if your child or adolescent have had any of these problems or symptoms recently:

Other:

Fears (circle):

   dying
   going crazy
   crowds
   dark
   animals
   other:

C. Have there been any recent illnesses or deaths among your family or close friends?
     ___ Yes ___ No

D. Have there been any recent crises or major changes in your life?
     ___ Yes ___ No

E. Has your child ever experienced any emotional, physical, or sexual abuse?
      ___ Yes ___ No

F. Has your child ever intentionally hurt himself or herself or made a suicide attempt?
     ___ Yes ___ No

G. Has your child taken medications for anxiety, depression, sleep, emotional conditions?
     ___ Yes ___ No
List them:

H. Has anyone in your family been in counseling or psychotherapy or had treatment from a psychiatrist before
     ___ Yes ___ No

 When and with whom:

I. Has anyone in your family had any hospitalization(s) for emotional problems?
     ___ Yes ___ No
When and where:

J. Please name any people or organizations that provide help and support to your family:

MEDICAL HISTORY

A. List any current medical conditions and disabilities of the child:

B. Is your child taking any medications? ___ Yes ___ No
List them:

C. List past medical conditions (include any surgeries):

D. Name of your physician(s) and their telephone number(s) and address(es):

E. Has your child had a medical exam within the past year? ___ Yes ___ No
Findings:

F. Indicate anyone in the family who has had these problems:

DRUG AND ALCOHOL USE

A. Please describe the drug and alcohol use of your family. Use the number which best states how often each person uses each drug. For your children, please write in the name of the child at the top of the column.
If the use is a problem, circle the number you enter.

B. Are you concerned about your child or adolescent's drug or alcohol use?
     ___ Yes ___ No

C. Does he or she get angry when others criticize the use of drugs or alcohol?
     ___ Yes ___ No

D. Are you concerned about the drug or alcohol use of someone else in your family?
     ___ Yes ___ No

E. Did your child grow up in a home at a time when a parent abused drugs or alcohol?
     ___ Yes ___ No

F. Did you grow up in a home in which a parent abused drugs or alcohol?
     ___ Yes ___ No

G. Age at child's first drink? ______________________

     Age of first use of other drugs?________________

LEGAL PROBLEMS

A. Has your child or adolescent ever been arrested (including OWI/DUI)?
     ___ Yes ___ No

B. Have you ever been involved with Protective Services?
     ___ Yes ___ No

C. Please list other legal problems:

SCHOOL AND WORK HISTORY

A. Is your child or adolescent currently enrolled in school? ___ Yes ___ No

B. Highest grade completed? __________________________

C. Describe child's usual performance in school? Has it changed?

D. If a parent is in school, what field and which school?

E. Occupation(s) of child's parent(s):

What strengths and good behaviors does your child have which will enable him or her to help resolve problems:

rev 5/25/06