Current Caregiver’s Autobiography

Boo Boo, Co-Therapist

Current Caregiver’s Autobiography

This form is to be completed by those who have the primary responsibility for the raising of the child (the adults who are around the child in the home the most). This could be the birth mother, the adopted mother, the two birth parents, the 2 adoptive parents, primary caregiver and fiancée, grandmother and grandfather, the grandmother and the mother, etc. A form must be filled out on each primary caregiver and submitted. It is acceptable for one caregiver to fill out the form for the other and submit for them.

Example: Two caregivers equals two forms. One form per caregiver.

The treatment plan cannot be written until all caregiver forms are submitted.

Name of person filling out this form

Relationship to Child:

Describe your mother and father (the positive and the negative).

How did your parents show affection to each other and to their children?

How did your parents handle disagreements and conflicts; what were their main methods of discipline?

How many siblings do you have and what role did each sibling play in the family?

Discuss your personal mental health history and your history of drug or alcohol use. This includes Marijuana.

Discuss family history of alcohol or drug abuse; physical, emotional or sexual abuse; and mental or emotional illnesses in the family; how was each issue dealt with?

Discuss any military history.

List any current/past illnesses/injuries that have impacted you or your family.

List any current and previous medications and the reasons for the prescriptions.

Describe your current marriage (positive and negative; i.e., communication, problem-solving, togetherness.)

Write a brief description of any previous marriages

List your children and give a brief description of each child (If you’ve not already done so on the child’s biography sheet.)

What are your main methods of discipline and how effective have they been?

How large of a role does spirituality play in your family?

Describe your positive attributes, strengths, and support systems

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