CSP Child & Adolescents History Form

Child & Adolescents History Form
Today's Date*

MonthDayYear
Date
Client Name*

First NameLast Name
Parent/Guardian's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Your History and What Brings You and Your Child to Counseling

Dear Parents and Guardians: Please fill out this form on behalf of your child. If your child is a teenager, it may be helpful to have a conversation with him or her as you fill in the information together.

It can be helpful to do a little thinking or writing about your child’s past life events, challenges and strengths. So take a few minutes to jot down your thoughts about the following areas of your child’s life. This will help us better get to know you and your child. For some people, writing down some or all of this information might be emotionally difficult. If so please fill out what you feel comfortable with. These questions will help clarify your child’s challenges, strengths, and experiences which will help us in our work together.
What made you contact us?
What made you and your child seek counseling? When did the challenges start? How do they affect your child’s daily life?
How do they affect your life and the life of your family?
How severe are the challenges?

MildModerateSevereVery SevereOther
What do you see as your child’s main strengths?
What do you see as your child’s main challenges?
What do you and/or your child most want to change?
What do you and/or your child want to stay the same?
Has your child been to counseling before? If so, with whom and for how long? Was it helpful?

FAMILY AND RELATIONSHIPS (CHILD)
Whom does your child live with currently (family members, pets, etc.)?
What are the most challenging relationships in your child’s life?
What are the most supportive relationships in your child’s life?
Describe any losses your family has experienced including pets, family, relationships, jobs, financial, opportunity.
Does your child/family ascribe to a religious faith?
Are there any family or cultural norms or issues that you would like to address in order for your counselor to better understand your child's needs or background?
Has your child experienced any kind of abuse or neglect?

EDUCATION (CHILD)
Where does your child go to school? What grade is he/she in? Who is his/her teacher?
Talk about your child’s strengths and challenges in the school environment (including academic, social and extra-curricular)
Does your child have an Independent Education Plan (IEP) or a 504 Plan for social and emotional support?
What is your child’s favorite part of school?

LEISURE AND RECREATION (CHILD)
What does your child do for fun?
What activities has he or she let go of that he/she used to enjoy?
What are your child’s relationships like with peers?
How much time per day does your child spend on a screen (video games, TV, phone, social media, etc.)
Does your child access social media regularly?

HEALTH (CHILD)
What physical health challenges has your child experienced in the past? Currently experiencing?
Please describe mother's physical and emotional health during pregnancy with child?
Is your child currently taking any medication?
Does your child have allergies (food, drugs, environmental)? If so, what are the effects of exposure?
Describe your child’s weekly physical activity.
Describe your child’s typical diet.
Does your child or anyone in your family abuse drugs or alcohol?
How’s your child’s sleep? Does he/she wake up refreshed? Have a regular bed and rising time?
When was your child’s last medical check up?
What illnesses run in your family?
If anyone has attempted or completed suicide in your family, please describe.

WORK AND MONEY (PARENTS/GUARDIANS INFORMATION)
Each Parent/Guardian: Please describe your work situation.
How would you rate the stress level of your job if you are currently working?
If you have served in the military, please list the dates and what it was like for you. Did you see active duty?
How do you manage money? Do you have enough to meet your bills each month?
What dreams have you postponed or given up on?

LEGAL ISSUES (PARENT/GUARDIAN AND/OR CHILD)
What legal issues have you or your child faced such as criminal charges, lawsuits, mediation, custody, divorce or jail? How did it work out? (Please include any contact with the Juvenile Justice System)
Are there custody issues and or arrangements for your child? Please describe.
Who has legal custody of child, if not parents? Please provide documentation at first visit.*
Who has access to your child's medical records?*

WELL-BEING (CHILD)
Does your child seem to feel safe at home? At school?
Do you have any concerns about your child’s emotional health or behavior?
Has your child ever threatened to harm himself/herself OR someone else? Please tell us about this.
Are there any weapons in your home? If so, are they secure?
What sorts of play or activities have increased your child’s sense of well-being? What is your child into currently?
What else would you like to express? Or like us to be aware of?
Should be Empty:

Child & Adolescents History Form

What made you contact us?

FAMILY AND RELATIONSHIPS (CHILD)

EDUCATION (CHILD)

LEISURE AND RECREATION (CHILD)

HEALTH (CHILD)

WORK AND MONEY (PARENTS/GUARDIANS INFORMATION)

LEGAL ISSUES (PARENT/GUARDIAN AND/OR CHILD)

WELL-BEING (CHILD)