Family History Questionnaire

Siblings

Is the child or any siblings adopted? If so, please explain:
List any other people living in the household:
If applicable, give date(s) of child's parents' marriage, separation(s) and/or divorce:
Comments about custody/visitation* (if applicable
*Please provide therapist copy of custody/visitation documentation.
Who does your child regard as the most supportive in their life?(specific family members, teacher, coach, friends, pets, etc.)
Describe any family history of mental health or chemical dependency problems or treatment:
Is child presently in any childcare setting?

YesNo
If yes, how many times per week?
List any involvement with social services, child protection, the court system or legal services:

Family History Questionnaire

Page 3
PREVIOUS TREATMENT
List any counselors/therapists/psychiatrists seen in the past and reason for visits:
List dates of any psychiatric hospitalizations or other out of home placements:

Psychotropic Medication History:

Does your child or another child in your family receive any other services at Therapy Associates? (please check all that apply)

Speech TherapyOccupational Therapy
If yes, Current or Past?

CurrentPast
OTHER
What are your child's strong points?
Is spirituality and/or faith system or other cultural influences important in your family?
In your child?
Additional comments: