PERSONAL HISTORY QUESTIONNAIRE Other Household Member

PERSONAL HISTORY QUESTIONNAIRE

(Please complete in its entirety. For all household members over the age of 18)
North Texas Family Services, PLLC

Lauren Gordon, LCSW

Mailing address: 8301 Lakeview Parkway Suite 111-131, Rowlett TX 75088
Cause Number
Identifying Information: Primary Party/Parent

All other adults in the home will need to complete this form as well.

Please answer all questions completely.
Last
First
Middle
Maiden/Other names by which you are known
Street
Apt
City
State
Zip Code
Work
Cell
Age
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Drivers License
Social Security Number
Household Information
Other adults who live in your home:
Adult #1

First NameLast Name
Adult #1 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult #1 SSN
Adult #2

First NameLast Name
Adult #2 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Adult #2 SSN
Please list additional adults here:
Type of residence
Do you own or rent?
Current value
Monthly payment
How long at present address
How many times have you moved in the last 10 years?
# of Bedrooms
# of Bathrooms
Please list all previous addresses and years at each residnece
Military and Education History
Branch
Date of enlistment

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of discharge

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Status
Highschool and Year Graduated
If your received a GED please complete the last grade completed and year you received your GED
Post Highschool Education
include college or trade school attended, degree earned, and year attended
Marital/Relationship History List, in chronological order, all marriages, cohabitation or long term relationships,. Please also include any relationships resulting in children, even if the relationship is not considered significant. Include your current relationship. Use additional pages if necessary.
Name of partner
Date of marriage or cohabitation:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of divorce or separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Names of children if any
Name of partner
Date of marriage or cohabitation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of separation

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date of divorce if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Names of children if any
Date of divorce if applicable

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Has there been any violence in any of your relationships, whether police were called or not?
If yes, please explain with who and circumstances:
Employment History

Please include employment history for the past 10 years.
Employer Name and Address (start with the most current first)
Dates of Employment
Reason for Leaving
Employer Name and Address
Dates of Employment
Reason for Leaving
Employer Name and Address (start with the most current first)
Dates of Employment
Reason for Leaving
Medical History

If you take any prescription medication, have a physical disability, chronic medical condition, or received psychiatric, psychological, or other behavioral health treatment, evaluation or counseling, please complete the followng information.
List any prescription medications you currently take with the dose and treatment provider's name.
Have you ever been hospitalized in a behavioral or psychiatric hospital?
Please list any hospitalizations you have had in the last 5 years INCLUDING behavioral health hospital stays.
Have you ever participated in mental health counseling/therapy?
If yes, please provide the name of your current therapist, previous therapist(s), dates you attend/attended therapy and a brief description of the situation.
Have you ever been treated for alcohol or substance abuse (this includes prescribed medication)

Other
If you stated yes above, please explain here:
Do you have any criminal history:
Please explain criminal history charges. Include arrest date, charge, probation and/or incarceration and release from charges.
Please provide the name of your probation or parole officer:

First NameLast Name
Please provide the telephone number of the probation or parole officer
Format: (000) 000-0000.
Has a protective order been issued against any person involved in the case?

Identifying Information: Children - List the child or children involved in the court action.

School/daycare name and address
Has there ever been a protective order issued against you?
Please explain protective order factors:
Income and Budget
Please list your monthly income (not including spouse or child support).
Please provide Mrs. Gordon with a pay stub or most recently filed W2.
Please provide any child or spousal support you receive.
Approximately how much are your monthly bills?
List the primary children associated with this case:
Child #1

First NameLast Name
Child #1 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #1 SSN
Child's School or Daycare and Grade
Child #2

First NameLast Name
Child #2 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #2 SSN
Child's School or Daycare and Grade
Child #3

First NameLast Name
Child #3 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #3 SSN
Child's School or Daycare and Grade
If you need additional room, please complete here:
What is the current allocation of parenting time between parents access visitation arrangements
Pediatrician's name:

First NameLast Name
Telephone number of the children's primary physician.
Format: (000) 000-0000.
Other children in the home:
Child #1

First NameLast Name
Child #1 DOB

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child #1 SSN
Child's School or Daycare and Grade
Have any of the children been treated for a current or chronic health problem? If yes, which child, for what condition, and by who
Have any of the children received any behavioral/mental health counseling or treatment? If yes, which child, for what condition, and by who?
Are there any individuals who live with your part time, or full time who are not listed on this form? If yes, give their names, ages, and relationship to you:
Has anyone involved in this case ever been involved with Child Protective Services?

Other
If yes, please list dates, county, a brief description of the allegation and final outcome (ruled out, reason to believe, unable to determine or list unknown)
Please answer the following questions.

If the question does not apply to your situation you may mark N/A.
1. What do you feel are the children's needs, strengths and weaknesses?
2. Describe yourself as a parent, focusing on your strengths.
3.Briefly describe your childhood, including who raised you and how. Include what resource or support your extended family is to you and the children.
I agree these are my answers and my answers alone.
Should be Empty:

PERSONAL HISTORY QUESTIONNAIRE

Household Information

Other adults who live in your home:

Military and Education History

Employment History

Medical History

Income and Budget

List the primary children associated with this case:

Other children in the home:

Please answer the following questions.