Adult History Form - Guardianship

Personal History

Today's date

Client's name:

Client's Date of Birth:

Age:

Your name and relationship to client:

Contact Information:

Client's current location:

City:

Social History

City and State of birth:

Who raised you?

How many brothers and sisters do you have?

What did your father do for a living while you were growing up?

What did your mother do for a living while you were growing up?

How old where you when they divorced?

If they did not get divorced, put N/A

Report if parent(s) died, which parent, when and how death happened:

Report abuse or violence growing up:

If none, put N/A

Report foster care or residential placement:

i.e. age, place, reason, length of stay

Number of times divorced:

Number of times widowed:

If other, please explain:

Report who else lives in the home with you:

Current relationship status: (i.e. single, divorced, widowed)

Number of children:

If child(ren) are under 18, and not living with you, describe current living arrangements:

Educational History

Name of last school attended:

Year graduated from high school:

If not, put N/A

If obtained GED, year obtained:

If not, put N/A

If you did receive special educational services, please report what grades and reason:

If you did go to an alternative school setting, what grade(s) and what reason:

If you did repeat a grade, which one(s) and what reason:

If you have taken any college or vocational classes, when, name of school, and study:

If you have a college or vocational certification or degree, report year, type of degree, in what decipline, and from college

i.e. 1994- associate degree in nursing from SCC

Employment History

Add new row

If you have been in the military, report branch, year enlisted/commissioned, rank at discharge, year discharged, type of discharge, MOS

i.e. USMC, March 1987-July 1991, Honorable, E-4/Cpl, 6541-Aviation Ordnance

Medical and Psychological History

Report hospitalizations for any medical or surgeries:

i.e. date, hospital name, and reason

Report hospitization for any mental health problems:

i.e. date, hospital name, and reason

Report any emergency room services in the past year:

i.e. hospital name, reason, and treatment provided

Report any history of loss of consciousness or brain injury treatment:

i.e. date, hospital, treatment, length of stay

Current therapies being provided:

Speech

Psychotherapy

Other Therapy

Primary Care Doctor:

Psychiatrist:

Counselor:

Current Medications:

Add new row

Legal History

Has your driver's license ever been suspended or revoked? If yes, when and what was the reason:

Add new row

Has anyone gotten a restaining order or emergency protective order against you? If yes, who and when?

Activities of Daily Living

Report the activities you do on a typcial day:

Time you go to bed:

Time you get up for the day:

How many hours do you spend each week doing chores?

What other activities take up your time?

If you did not check an item, describe the reason:

Report what the individual does for fun/hobby:

Any other concerns:

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Adult History Form - Guardianship

Personal History

Social History

Educational History

Employment History

Medical and Psychological History

Current Medications:

Legal History

Activities of Daily Living

Annette Freel, M.S., L.P.P.

Licensed Psychological Practitioner, Kentucky Psychological Services