Adolescent Personal History

Name

First Name Last Name
Date

Month Day Year
Date
Gender
Date of Birth

Month Day Year
Date
Age
Form completed by (if someone other than client):
Address

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.
Primary Reason(s) for seeking services:

Anger management Eating Disorder Sleeping problems Anxiety Fear/phobias Addictive behaviors Coping Mental confusion Alcohol/drugs Depression Sexual concerns Other
Family Information
Parents
With whom does the child live with?
If Other, please explain.

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

	Age
Began puberty
Voice change
Menstruation
Breast development
Convulsions
Injuries or hospitalizations

Family Information

	DPT	Polio
2 months MMR (Measles, Mumps, Rubella
4 months HEPV (Hib)
6 months
15 months
18 months
24 months
4-5 years

	Yes/No	When	Where	Your reaction/ overall experience
Counseling/Psychiatric treatment
Suicidal thoughts/attempts
Drug/alcohol treatment
Hospitalizations
Involvement with self-help groups (NA, AA ect..)

	Yes/No	When	Where	Your reaction/ overall experience
Counseling/Psychiatric treatment
Suicidal thoughts/attempts
Responsiveness
Drug/alcohol treatment
Hospitalizations
Involvement with self-help groups (NA, AA ect..)