Adolescent Personal History

First Name

Last Name

Date

Date of Birth

Age

Form completed by (if someone other than client)

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

If Other, specify

Family Information

Parents

With whom does the child live with?

Both parents Mother Father Other

If Other, please explain.

Mother

Name

Age

Father

Name

Age

Sibling

Add new row

Other

Add new row

Parental Information

Parents legally married Parent have been separated Parents ever divorced Parents never married

If not married, who has legal custody?

Is there any significant information about the parents' relationship or treatment toward the child, which might be beneficial in counseling?

Yes No

If Yes, please explain.

Adolescent Personal History
Child

Father

Client's Father: First Name

Last Name

Age

Occupation

Father's Education

Father's Employer

Father is

Natural Parent Step-parent Adoptive parent Foster home Other

If 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?

Mother

Client's Mother: First Name

Last Name

Age

Occupation

Mother's Education

Mother's Employer

Mother is

Natural Parent Step-parent Adoptive parent Foster home Other

If 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?

Family Health History

If Other, specify

Comments related to family health

Spiritual/Religious

How important to you are spiritual matters?

Not Little Moderate Much

Are you affiliated with a spiritual or religious group?

Yes No

If Yes, please describe

Would you like your spiritual/religious beliefs incorporated into the counseling?

Yes No

If Yes, please describe

Childhood/Adolescent History

Pregnancy/Birth

Has the child’s mother had any occurrences of miscarriages or still borns?

Yes No

If Yes, please describe

Was the pregnancy with child planned?

Yes No

Length of pregnancy

Mother's age at birth

Father's age at birth

How many pounds did mother gain during pregnancy?

Did mother smoke while pregnant?

Yes No

If Yes, What amount?

Did mother use drugs or alcohol while pregnant?

Yes No

If Yes, What type and amount?

While pregnant, did the mother have any medical or emotional difficulties? (e.g., surgery, hypertension, medication) describe below.

Length of labor

Induced labor

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 for mother.

Length of hospitalization for baby.

Infancy/Toddlerhood

Developmental History

Please note the age at which the following behaviors took place

Sat alone

Age

Took 1st steps

Age

Spoke words

Age

Spoke sentences

Age

Weaned

Age

Fed Self

Age

Dressed self

Age

Tied shoelaces

Age

Rode 2 wheeled bike

Age

Toilet trained

Age

Dry during the day

Age

Dry during the night

Age

Compared to others in the family, child's development was

Slow Average Fast

Age for following developments

Began puberty

Age

Voice change

Age

Menstruation

Age

Breast development

Age

Convulsions

Age

Injuries or hospitalizations

Age

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

Education

Type of school

Public Private Home school Other

If other, specify

In special education?

Yes No

If yes, describe

In gifted program?

Yes No

If yes, describe

Has child been held back in school?

Yes No

If yes, describe

Which subjects in school does child enjoy?

Which subjects in school does child dislike?

Which grades does child usually receive in school?

Has there been any recent changes in child's grades?

Yes No

If yes, describe

Has the child been tested psychologically?

Yes No

If yes, describe

Feelings about school work

Anxious

Passive

Enthusiastic

Fearful

Eager

Bored

Rebellious

Other

If Other, specify

Child's Peer Relationships

Spontaneous

Leader

Difficulty making friends

Other

If Other, specify

Who handles responsibility for the following areas?

School

Mother

Father

Both

Other

If Other, specify

Health

Mother

Father

Both

Other

If Other, specify

Problem behavior

Mother

Father

Both

Other

If Other, specify

Employment/ Vocational Program

What is the child's attitude toward work?

Poor

Average

Good

Excellent

Has the child's grades been affected since working?

Lower Higher Same

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.)

Activity, How often, How often in the past

Medical/Physical Health

If Other, specify

List any current health concerns

List any recent health or physical changes

Nutrition

Meals

Breakfast

Times per week eaten

Typical foods eaten

Lunch

Times per week eaten

Typical foods eaten

Dinner

Times per week eaten

Typical foods eaten

Snacks

Times per week eaten

Typical foods eaten

Comments

Medical

Results

Current prescribed medication(s)

Current over the counter medication(s)

Name, Dose, Dates, Purpose, Side effects

Are you allergic to any medications or drugs?

Yes No

If Yes, describe

Immunization record (check immunizations the child/ adolescent has received)

2 months

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

4 months

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

6 months

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

15 months

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

18 months

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

24 months

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

4-5 years

DPT

Polio

MMR (Measles, Mumps, Rubella)

HEPV (Hib)

Prior to school (HepB)

Chemical Use History

Does the child/adolescent use or have a problem with alcohol or drugs?

Yes No

If Yes, describe

Counseling/Prior Treatment History

Where

Your reaction/ overall experience

If Other, describe

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

At what age?

If Yes, describe the child/adolescent's reaction

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

Yes No

If Yes, describe the child/adolescent's reaction

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

By Submitting this form via this web portal, you acknowledge and accept the risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Submit" you agree to hold SOS Life Ring harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.

Your information will be encrypted.

Adolescent Personal History

Family Information

Parents

Mother

Father

Sibling

Other

Adolescent Personal HistoryChild

Father

Mother

Family Health History

Spiritual/Religious

Childhood/Adolescent History

Pregnancy/Birth

Infancy/Toddlerhood

Developmental History

Please note the age at which the following behaviors took place

Age for following developments

Education

Employment/ Vocational Program

Leisure/Recreational

Medical/Physical Health

Nutrition

Meals

Breakfast

Lunch

Dinner

Snacks

Medical

Please fill out below

Last physical exam

Last doctor's visit

Last dental exam

Most recent surgery

Other surgery

Upcoming surgery

Immunization record (check immunizations the child/ adolescent has received)

Chemical Use History

Counseling/Prior Treatment History

Information about Client (past and present)

Counseling/Psychiatric treatment

Suicidal thoughts/attempts

Drug/alcohol treatment

Hospitalizations

Involvement with self-help groups (NA, AA etc..)

Information about Family/Significant Other (past and present)

Counseling/Psychiatric treatment

Suicidal thoughts/attempts

Responsiveness

Drug/alcohol treatment

Hospitalizations

Involvement with self-help groups (NA, AA etc..)

Adolescent Personal History
Child