MINOR – BACKGROUND & HISTORY

"*" indicates required fields

Who is your provider?*

Today’s date*

Client Legal Name*

First Middle Last

Client Preferred Name*

First Middle Last

Date of Birth*

Street Address*

Street Address Address Line 2 City State ZIP Code

Preferred Email Address*

Would you like to subscribe to our newsletter?*

Yes, keep me up to date with latest news and updates.

Client's Preferred Phone*

Phone Type*

Cell

Home

Work

Current school*

Grade*

Gender Identity*

Sex Assigned at Birth*

Parent(s)/Guardian(s)*

Parent(s) Email Address*

Preferred Phone & Whose*

Phone Type*

Cell

Home

Work

Preferred Phone & Whose*

Phone Type*

Cell

Home

Work

Referred by*

Prior Mental Health Care

First Mental Health Care

When?*

Where?*

Diagnosis (if applicable)?*

Most Recent Care

When?*

Where?*

Diagnosis (if applicable)?*

FINANCIALLY RESPONSIBLE PARTY

An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.

Name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact*

Relationship*

Phone*

PRESENTING PROBLEM(S)/ SYMPTOMS: (type and duration). How do these impact your functioning (at home, work, school, interpersonally)?*

HISTORY OF DIFFICULTY AND PRECIPITATING FACTORS*

PSYCHIATRIC TREATMENT HISTORY, MEDICATIONS*

If none reported, check here

None reported

PERTINENT BACKGROUND*

(# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)

MEDICAL HISTORY*

(Current & past medications & dosages, illnesses, etc.)

If none reported, check here

None reported

SUBSTANCE USE AND ANY SUBSTANCE ABUSE HISTORY*

(Client or Family)

If none reported, check here

None reported

SOCIAL/SPIRITUAL/INTERPERSONAL SUPPORT SYSTEM OR ACTIVITIES*

If none reported, check here

None reported

LEGAL ACTIVITY*

(Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)

If none reported, check here

None reported

Abuse &/or Neglect*

Yes

Delinquency*

Yes

If Yes to any of the above, please list contact person

What are your child’s strengths, or other things your child is particularly good at or enjoy doing?*

Youth History Section

(to be completed by parent or guardian of minor client)

Parent One’s Name*

First Last

Date of Birth*

Address if different from client*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)*

Phone (work)*

Phone (cell)*

Highest Grade Completed*

Occupation*

Employer*

Marital Status*

Length of Time Married*

Year of divorce*

Mental Health Treatment History*

Yes

Parent Two’s Name

First Last

Date of Birth

Address if different from client

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)

Phone (work)

Phone (cell)

Highest Grade Completed

Occupation

Employer

Marital Status

Length of Time Married

Year of divorce

Mental Health Treatment History

Yes

Stepparent One’s Name

First Last

Date of Birth

Address if different from client

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)

Phone (work)

Phone (cell)

Highest Grade Completed

Occupation*

Employer

Length of Time Married

Mental Health Treatment History

Yes

Stepparent Two's Name

First Last

Date of Birth

Address if different from client

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (home)

Phone (work)

Phone (cell)

Highest Grade Completed

Occupation

Employer

Length of Time Married

Mental Health Treatment History

Yes

Legal Custody of Client is

First Last

Signature*

Date*

Pregnancy and Birth History

Length of pregnancy*

Birth weight of child*

Did child go home with mom?*

Yes

Any difficulties during pregnancy (nausea, illnesses, medication, smoking or alcohol)?

Any complications during birth?

Describe your child as an infant (e.g. happy, active, quiet, and fretful)*

Any other important information about pregnancy, birth or infancy?*

Developmental History

At what age did your child?

Sit up

Crawl

Stand

Walk

First word

What was the word?

First sentence

What was it?

Toilet trained daytime

Toilet trained at night

Any Toileting Accident Now?*

If Yes, when?

What were your child’s preferences in play during early years (2-4 years of age)?

Home and Community

Activity Level at Home*

Age of Friends*

Ability to Get Along*

Other family members and ages

(please note whether living in or outside of the home)

Have there been any changes in the family that may present difficulties for your child?

Other places your child spends significant time (i.e. daycare, grandparents)?

How much time per day is spent watching television?*

How much time per day is spent on a laptop or computer?*

For entertainment or school?*

How much time per day is spent on a phone?*

Preferred games to play?

What are your child’s extra-curricular activities?*

How and when do you discipline your child?*

Did your child attend preschool?*

Yes

If yes, what age?

At what age did s/he go to kindergarten?*

Was your child ever retained?*

Yes

If yes, what age?

Describe your child’s educational experience. Include if your child has ever been home schooled and when, or changed schools (when and why).*

Does your child have

History of excellent attendance (out for infrequent illness)

Fair attendance history

History of multiple excused absences (please elaborate below)

History of cutting school (please elaborate below)

Elaborate below

What are your child’s academic/school related strengths?*

What are your child’s academic/school related difficulties?*

Any changes in your child’s grades?

Present health of client*

Previous medication (not for common illnesses)

Current medications (include all and who is prescribing them)

Has your child been hospitalized or had surgeries (please describe)

Last Vision Test Date

Does your child wear glasses?*

Yes

If Yes, When?

Last Hearing Test Date

Does your child use hearing aids?*

Yes

Immunizations up to date?*

Yes

Any family history of mental health concerns?*

(i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)

Prior Psychological Evaluations/Treatment

Has your child been evaluated previously?*

Yes

If yes, please indicate where this occurred, when and why the evaluation was conducted.

Is your child currently receiving special education services?*

Yes

Is your child currently receiving counseling or therapy services elsewhere?*

Yes

If yes, please indicate name of provider and length of time being seen?

Is your child currently receiving counseling or therapy services elsewhere?

Any other information that you feel is important for me to know?*

Other Contacts

Other care professionals you are currently undergoing treatment with (e.g. other medical professionals such as acupuncturist, chiropractor, medical specialists, etc.)

Physician*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

School*

Phone*

Address*

Street Address Address Line 2 City State ZIP Code

Teacher(s)

Phone

Teacher(s)

Phone

Teacher(s)

Phone

Guidance Counselor

Phone

Dean or Principal

Phone

Nurse

Phone

JSO

Phone

Address

Street Address Address Line 2 City State ZIP Code

Guardian

Phone

Address

Street Address Address Line 2 City State ZIP Code

Probation Officer

Phone

Address

Street Address Address Line 2 City State ZIP Code

Other

Phone

Address

Street Address Address Line 2 City State ZIP Code

Name

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