Background History Form

In order to make the best use of our time during the intake session, we would like to know as much as possible about your concerns and your or your child’s background. We have found that asking many of our questions ahead of the intake makes it easier for everyone involved. Please answer the following questions to the best of your ability. Because we work with clients with a wide range of ages, backgrounds, and challenges, some of the following items will probably not apply to you or your child's case. We live in a diverse world and hope to not overlook possibilities. The more you tell us, the better job we can do to address your concerns. If a section of the questionnaire does not apply to you or your child (for example, occupational history for a child) or if you prefer not to answer any questions, that is fine - just skip to the next one.

Please provide us with additional contact information of important persons in the primary patient's life - We will never share them with others without your permission

The following questions help us to understand the patient's growth and development, which is sometimes useful in understanding their current situation. Many of the items may not apply, or may be hard to remember, but please give us as much information as you can!

Briefly describe the primary patient's performance and any concerns in each grade

Does the primary patiene currently have any of the following concerns?

Ongoing medical illness associated with?

What substances has the patient either previously or currently used