MINOR – BACKGROUND & HISTORY

Who is your provider?*
Today’s date*
MM slash DD slash YYYY
Client Legal Name*
First Middle Last
Client Preferred Name*
First Middle Last
Date of Birth*
Month
Day
Year
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
- No
Delinquency*
- Yes
- No
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*
Month
Day
Year
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
- No
Parent Two’s Name
First Last
Date of Birth
Month
Day
Year
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
- No
Stepparent One’s Name
First Last
Date of Birth
Month
Day
Year
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
- No
Stepparent Two's Name
First Last
Date of Birth
Month
Day
Year
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
- No
Legal Custody of Client is
First Last
Signature*
Date*
MM slash DD slash YYYY
Pregnancy and Birth History
Length of pregnancy*
Birth weight of child*
Did child go home with mom?*
- Yes
- No
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
- No
If yes, what age?
At what age did s/he go to kindergarten?*
Was your child ever retained?*
- Yes
- No
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
Month
Day
Year
Does your child wear glasses?*
- Yes
- No
If Yes, When?
Month
Day
Year
Last Hearing Test Date
Month
Day
Year
Does your child use hearing aids?*
- Yes
- No
Immunizations up to date?*
- Yes
- No
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
- No
If yes, please indicate where this occurred, when and why the evaluation was conducted.
Is your child currently receiving special education services?*
- Yes
- No
Is your child currently receiving counseling or therapy services elsewhere?*
- Yes
- No
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
Phone
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MINOR – BACKGROUND & HISTORY

Prior Mental Health Care

FINANCIALLY RESPONSIBLE PARTY

Youth History Section

Pregnancy and Birth History

Developmental History

Home and Community

Prior Psychological Evaluations/Treatment

Other Contacts