Life History Child/Adolescent, (ages 0-13)

Life History Child/Adolescent

(ages 0-13)

CONFIDENTIAL
UnknownOther
PERSON COMPLETING FORM

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Name of person completing this form*

First NameLast Name
Relationship to the client
Best Phone Number
Format: (000) 000-0000.
Email
example@example.com
CLIENT DETAILS

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Client's Name*

First NameMiddle InitialLast Name
Client's Preferred Name
Client Birthdate

MonthDayYear
Date
This is my Natural ChildThis is an Adopted ChildThis is a Foster Child
NormalBreechPrematureFull-termCesareanOther
If your Natural Child was premature, indicate the number weeks
What was the Birth weight of your Natural Child?
Were their problems at birth with your Natural Child? (for example: infant given oxygen, blood transfusion, placed in an Incubator, etc.)
If this is an Adopted Child, at what age was the child adopted?
If this is a Foster Child, at what age did the child come to you?
YesNoOther
Parents or Guardian Names
List child's #1 Parent/Guardian Name

First NameLast Name
List child's #2 Parent/Guardian Name

First NameLast Name
Indicate Relationship Status of Parents/Guardians:
Indicate Custody Agreement
List Name of Person Responsible for Child's Account:
List others who live in the home with the child? (Mom, dad, siblings, grandparents, etc.)
Describe the child's relationship with their mother:
Describe the child's relationship with their father:
List Child's Brothers & Sisters
Please describe child's relationship with siblings.
EDUCATION

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What school is the child attending?
What is the last completed grade of the child?
PoorUnsatisfactorySatisfactoryGoodVery Good
PoorUnsatisfactorySatisfactoryGoodVery Good
Does the child now, or have they in the past, attended special classes such as resource programs or gifted programs? Provide details:
Does the child have a learning disability? Describe:
PHYSICAL HEALTH INFO

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Primary Physician Name:
Primary Physician Phone Number
Format: (000) 000-0000.
Date of Last Physical:

MonthDayYear
Primary Physician Address

Street Address

Street Address Line 2

CityState

Zip Code
YesNo
If yes, describe and give dates
YesNo
If yes, indicate type of testing, where, when
How much exercise does the child generally get in a week?
What exercise or sports does the child participate in regularly?
About how many hours does the child watch TV, videos, etc., per day
What does the child like to do for fun/enjoyment?
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)
How would you rate the child's overall health at present time
MENTAL HEALTH INFO

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Why are you bringing the child to counseling? Was there a specific event or situation that occurred? When did it happen or start? How is the child's or family's life affected by this issue? Please be as detailed as you can.*
What do you think your child needs the most help with right now?*

Indicate the intensity of the child’s emotional distress:

	1	2	3	4	5	6	7	8	9	10

1 is Mild, 10 is Severe

Please describe the emotional distress:

Overall, how much do the problems affect the 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

1 is Mildly disruptive, 10 is Incapacitating

Please describe
When did these problems start? What was going on in the child’s life at that time?
YesNo
Please tell us about any other mental health professionals the 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).
YesNo
If yes, please describe why, when, and length of stay
YesNo
If yes, how often
YesNo
If yes, how long ago?

For each area below indicate the severity of your concern. (No Concern, Mildly Concerned, Moderately Concerned, or Highly Concerned):

Rows	No Concern	Mildly Concerned	Moderately Concerned	Highly Concerned
Depression
Frequent crying
Anxiety/Worry
Panic Attacks
Friends
School
Anger Issues
Food/Eating Issues
Sleep Issues
Frequent Nightmares
Self-Harming Behaviors
Substance Use
Attention Problems
Temper Tantrums
Mood Swings
Low energy
Excess Energy
Irrational Fears
Impulsive behaviors

Any other concerns?
FAMILY HISTORY

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Does any family member struggle with the following challenges?

Rows	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

Should be Empty:

PERSON COMPLETING FORM

CLIENT DETAILS

Parents or Guardian Names

EDUCATION

PHYSICAL HEALTH INFO

MENTAL HEALTH INFO

FAMILY HISTORY