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Life History Child/Adolescent
CONFIDENTIAL
Click on Age of Client
*
Under 14
15 to 18
Name of therapist the client is scheduled with
*
Unknown
Other
Name of person completing this form
*
First Name
Last Name
Your relation to the client
Best Phone Number
Email
example@example.com
Client Details
Client's Name
*
First Name
Middle Initial
Last Name
Client's Preferred Name
Natural Child
Yes
No
If adopted, at what age?
Foster since
Does your family practice a religion/faith?
Yes
No
If yes, please indicate faith?
Parent/Guardian #1 Name
First Name
Last Name
Parent/Guardian #2 Name
First Name
Last Name
Parents Relationship Status
Custody Agreement
Person Responsible for Account
Who lives in the home with you/your child? (Mom, dad, siblings, grandparents, etc)
Brothers & Sisters
Under 14
School History
What school is your child attending?
What grade is your child in?
Please Select
Pre-school
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
How would you rate your child's academic performance in school?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
How would you rate your child's behavior in school?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Does your child now, or have they in the past, attended special classes such as resource programs, gifted programs?
Do your child have a learning disability? What is it?
Developmental/Medical History
Pregnancy
Delivery:
Normal
Breech
Premature
Full-term
Cesarean
Other
If premature, # of weeks
Birth weight
Problems at birth: (for example: infant given oxygen, blood transfusion, placed in an Incubator, etc.)
Primary Doctor Information
Primary Physician:
Primary Physician Phone Number
Date of Last Physical:
/
Month
/
Day
Year
Primary Physician Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Does your child have a history of serious illness, injury, handicaps, or hospitalization?
Yes
No
If yes, describe and give dates
Is your child currently taking any medications?
Yes
No
If yes, name medications
Any previous testing (school/psychological)?
Yes
No
If yes, indicate type of testing, where, when
Current Medical Diagnoses
How much exercise does your child generally get in a week?
What exercise or sports does your child participate in regularly?
About how many hours does your child watch TV, videos, etc., per day
What does your child like to do for fun/enjoyment?
Please list any persistent physical symptom, health concern, or any other information you'd like me to know
Mental Health Information
Why are you bringing your child to counseling? Was there a specific event or situation that occurred? When did it happen or start? How is the child or family's life affected by this issue? Please be as detailed as you can.
*
How intense is your child’s emotional distress?
1
2
3
4
5
6
7
8
9
10
Mild
Severe
1 is Mild, 10 is Severe
Please describe
Overall, how much do the problems affect your child’s ability to perform school, get along with others, and perform daily tasks such as chores?
1
2
3
4
5
6
7
8
9
10
Mildly disruptive
Incapacitating
1 is Mildly disruptive, 10 is Incapacitating
Please describe
When did these problems start? What was going on in your child’s life at that time?
Has your child previously received any type of mental health services (therapy, psychiatric care, etc.)?
Yes
No
Please tell us about any other mental health professionals your child has consulted with in the past (approximate dates, type of professional seen, reason for the consultation, nature of the treatment, outcome of the treatment).
For each area of concern below indicate the severity of your concern
No Concern
Mildly Concerned
Moderately Concerned
Highly Concerned
Depression
Anxiety/Worry
Friends
School
Anger Issues
Food/Eating Issues
Sleep Issues
Self Harming Behaviors
Suicidal Thoughts
Sex
Substance Use
Legal
Any other concerns?
For each symptom below indicate the severity level your child is experiencing or has experienced in the past.
Never or Rarely
Sometimes
Often
Almost all the time
Headaches
Attention Problems
Pain / Chronic Pain
Excessive Anger
Sleep Difficulties
Excess Energy
Feeling Irritable
Mood Swings
Impulsive Behavior
Confusion
Eating or Appetite Problems
Weight Gain
Weight Loss
Frequent Nightmares
Low Energy
Unable to Have Fun
Suicidal Thoughts
Crying Frequently
Anxiety/Panic Attacks/Phobias
Frequent Worrying
Fears
Temper Tantrums
Behavior Problems
15 to 20
School History
What school/college/university are you attending?
What grade/level are you in?
Please Select
Highschool 9th Grade
Highschool 10th Grade
Highschool 11th Grade
Highschool 12th Grade
College Freshman
College Sophomore
College Junior
College Senior
If not in school, what was your last completed grade?
How would you rate your academic performance in school overall?
Poor
Unsatisfactory
Satisfactory
Good
Very Good
If attending school, what is school like for you?
When do you attend class? Please specify if online/in-person
Are these grades better or worse than usual?
Have you ever attended any special classes/schools, such as resource programs, gifted programs?
Have you ever been suspended or expelled from school? Provide details.
Do you have a learning disability? What is it?
Medical History
Primary Physician
Primary Physician Phone Number
Date of Last Physical:
/
Month
/
Day
Year
How would you rate your overall health at present time
Please Select
Poor
Unsatisfactory
Satisfactory
Good
Very Good
Are you sexually active?
Yes
No
If yes, do you practice safe sex?
Please list any persistent physical symptom or health concern (e.g. chronic pain, diabetes, headaches, etc.) :
Please list any medications you are currently taking (name, dosage, time taken)
What exercise or sports do you participate in regularly?
What do you like to do for fun or enjoyment? Do you have hobbies you enjoy regularly? Do you prefer these activities alone, with others, or both?
Mental Health Information
What is the reason you are coming for counseling?
*
What do you think you need the most help with right now?
*
Have you seen a mental health professional in the past?
Yes
No
If yes, please specify dates, reason for counseling, and diagnosis (if any)
Have you ever been hospitalized for a psychiatric reason?
Yes
No
If yes, please describe why, when, and length of stay
Have you had any suicidal thoughts recently?
Yes
No
If yes, how often
Please Select
Frequently
Sometimes
Rarely
Have you had any suicidal thoughts in the past?
Yes
No
If yes, how long ago?
Please rate your concerns in the following areas on a scale of 0 to 10 (0= no concern and 10= major concern)
0
1
2
3
4
5
6
7
8
9
10
Depression
Anxiety/Worry
Parents
Friends
Sex
Alcohol
Substance Use
Legal Problems
Anger Issues
Trouble Eating
Self-Harming Behaviors
Suicidal thoughts
Any other concerns?
Symptoms
Please check any symptoms that you have experienced.
N/A
Current
Past
How long ago
Restlessness
Racing thouhgts
Mood swings
Feeling irritable
Excess energy
Excessive anger
Excessive spending
Impulsive behavior
Low energy
Feeling isolated
Feeling worthless
Feeling hopeless
Attempted suicide
Self-harming behaviors
Anxiety
Frequent worry
Fears
Phobias
Panic attacks
Drug craving
Nicotine/vape use
Alcohol craving
Eating problems
Sleeping problems
Frequent nightmares
Concentration problems
Hearing voices others do not hear
Seeing things others do not see
Physical abuse
Sexual abuse
Emotional/verbal abuse
Family conflict
Relationship conflict
Obsessive/repetitive thoughts
Feeling the need to repeat things
Family History
Please describe your relationship with your mother.
Please describe your relationship with your father.
Please describe your relationship with your siblings.
If you are in a relationship, please describe the nature of it and time together
Does any family member struggle with the following challenges?
Mother
Father
Maternal Grandmother
Maternal Grandfather
Paternal Grandmother
Paternal Grandfather
Learning challenges/disabilities
Depression Disorder
Bipolar Disorder
Anxiety/panic attacks
Trauma (sexual assault, combat, abuse, etc.)
Eating disorders
Alcoholism/drug addiction
ADHD
Suicidal attempts
Submit
SUBMIT LIFE HISTORY
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