Child/Adolescent Psychosocial History

In preparation for our first appointment, please complete the information in the form below to the best of your ability. Feel free to leave any questions blank which are not relevant or which you would prefer not to answer, with the exception of the questions in the Concerns About Harming Self or Others section. Gathering a thorough history assists me in completing a comprehensive evaluation of your child/adolescent.

Identifying Information

Child's/Teen's Name*

First NameLast Name

Date of Birth*

Date

Ethnicity*

Gender Identification*

School or Childcare Setting*

School Grade Level*

Presenting Concerns

What concerns have led you to seek consultation now?

How long have you had these concerns?

Do others share your concerns? Please elaborate.

What strategies or resources have you already used to help your child/teen? What has worked? What hasn’t been successful?

Has your child/teen or family encountered recent stressors, family changes, or traumatic events?

Has any other family member struggled with similar issues?

Child's Strengths

What do you consider to be your child's/teen's strengths?

What activities does she/he/they enjoy?

To whom does your child/teen typically turn to for support?

Development

Was your child/teen adopted? If so, at what age? What information do you have about her/his birth family or genetic history? Was she/he/they in another placement(s) before coming to live with your family?

Please describe any reproductive technologies involved in your child's conception.

Please describe any medical concerns, psychological stressors and/or exposure to drugs/alcohol during the pregnancy or birth of your child.

Did your child require any medical assistance in the first days of life? If so, please explain.

Were there any concerns about your child reaching any developmental milestones late or with difficulty (e.g., walking, toileting, speech)?

How easy or difficult was your child to soothe as an infant? Currently?

Please describe your child’s/teen’s sleep patterns from infancy to present.

Please describe your child’s/teen’s eating habits from infancy to present.

If eating issues have been a source of tension in the family, please describe.

Who are your child’s/teen’s closest friends? Is she/he/they dating?

How did your child/teen adapt to the birth or entry of any subsequent children coming into the family?

How does your child/teen get along with siblings, provided they have any?

To the best of your knowledge, has your child/teen experienced any emotionally overwhelming and/or life-threatening event? If so, please describe:

Medical

Has your child/teen experienced any medical issues requiring treatment, surgery or hospitalization? If so, at what ages? What was the outcome?

Has your child/teen experienced any seizures or head injuries?

Please list any allergies your child/teen has and describe any interference with daily life.

Has your child/teen entered puberty? If so, at what age? How has she/he/they adapted to these changes?

Is your child/teen sexually active?

Who is your child’s/teen’s pediatrician?

Are there any other medical specialists who are working with your child/teen currently, including a psychiatrist?

Is your child/teen currently taking any medications? If so, which ones and what is the dosage?

Concerns About Harming Self or Other

This section is required.

Please describe any concerns you may have about bingeing, purging, restricting food, over-eating, compulsive exercise or other compulsive behavior. *

Please describe any concerns about your child’s/teen’s drug or alcohol use.*

Please describe any concerns you may have about any addictive behaviors (e.g., substances, pornography, video gaming)?*

Has your child/teen ever expressed a wish to die or attempted suicide?*

Has your child/teen engaged in self-harmful behavior (e.g., cutting, risk-taking, burning self)?*

Has your child/teen ever seriously harmed another person, property or animal?*

Education

How were your child's/teen's average grades in elementary/middle/high school?

Describe her/his/their involvement in extra-curricular activities in elementary/middle/high school.

Describe her/his/their relationship with peers, in general, in elementary/middle/high school.

Describe her/his/their relationship with teachers, in general, in grade school, middle school and high school.

Has child/teen had an IEP, tutoring, suspension or expulsion in elementary/middle/high school?

Composition of Family and Household

Please complete the following for each significant caregiver. This may include biological parents, step-parents, adoptive parents, or guardians.

Type a question

	Parent 1	Parent 2	Parent 3	Parent 4
Name
Relationship
Occupation
Relationship Quality

Please complete the following for each sibling.

Type a question

	Sibling 1	Sibling 2	Sibling 3	Sibling 4
Name
Age
Relationship
Relationship Quality

Are there any other adults or children living in the household(s)? If so, please list.

Are there any other adults who play a significant caregiving role in your child’s/teen’s life? If so, please describe.

If there has been a divorce or separation, what are the custody and visitation arrangements?

Family History

Please consider grandparents, great-grandparents, aunts, uncles, siblings and cousins when answering this set of questions:

Have family members suffered from significant medical conditions? If so, who and what?

Have family members endured trauma? If so, who and what?

Have family members had a history of emotional or mental disorder or suicide? If known, please include diagnosis and treatment.

Have family members experienced a history of alcoholism, substance abuse or excessive alcohol use? If so, please describe.

What strengths or positive traditions have been passed down or shared within the extended family?

Family Style and Resources

How would you describe the atmosphere in your household(s) (e.g., warm, tense, serious, playful)?

What activities do you enjoy as a family?

What are meal times like in your family?

Which friends, family or community members/agencies support your child or family?

If applicable, describe the role spirituality/religion has played in your family.

What are your child’s/teen’s favorite family rituals or routines?

Does your family have a pet?

Please describe the typical discipline practices in your home(s).

What behaviors do you reward or reinforce?

What behaviors receive consequences or punishment?

What are your strengths as a parent? Of your child’s other parent(s)?

What parenting skills would you like to improve?

What parenting skills would you like your co-parent(s) to work on?

Other

Who referred you to me?

Are there any other adults (e.g., teachers, family members, service providers) whom you would like me to consult about your child/teen?

What else would you like me to know or understand about your child/teen or family?

Signature of Person(s) completing the form*

Date*

Date