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Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)

Clients name _____________________________________________ Date _____________________________ Gender ____F ____ MDate of birth __________Age _______Grade in school Address ______________________________ City ________________State _____Zip: Phone (home) ____________________(work) _____________________(cell) Form completed by (if someone other than client) If you need more space for any of the following questions, please use the back of the sheet. Primary reason(s) for seeking services:
____ Anger management ____ Eating disorder ____ Sleeping problems ____ Anxiety ____ Fear/phobias ____ Addictive behaviors ____ Coping ____ Mental confusion ____ Alcohol/drugs ____ Depression ____ Sexual concerns ____ Hyperactivity

____ Other mental health concerns (specify): ______________________________________________

FAMILY HISTORY Parents With whom does the child live at this time? Are parents divorced or separated?

Were the childs parents ever married? ____ Yes____ No Is there any significant information about the parents relationship or treatment toward the child which might be beneficial in counseling? ____ Yes____ No If Yes, describe: Clients Mother Name _______________________________ Age ____Occupation ____________________ FT__ PT Where employed ______________________________Work phone Mothers education Mothers cell phone ______________________ Is the child currently living with mother? ___ Yes ___ No ___ Natural parent ___ Stepparent ___ Adoptive parent ___ Foster home ___ Other (specify): __________ Is there anything notable, unusual or stressful about the childs relationship with the mother? ____ Yes____ NoIf Yes, please explain : _______________________________________________ ___________________________________________________________________________________ How is the child disciplined by the mother? For what reasons is the child disciplined by the mother?

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
Clients Father Name _______________________________ Age ____Occupation ____________________ FT__ PT Where employed: _________________________________Work phone: Fathers education: Fathers cell phone ______________________ Is the child currently living with father? ___ Yes ___ No ___ Natural parent ___ Stepparent ___ Adoptive parent ___ Foster home ___ Other (specify): _______ If there anything notable, unusual or stressful about the childs relationship with the father? ____ Yes____ NoIf Yes, please explain:

How is the child disciplined by the father? For what reasons is the child disciplined by the father? CLIENTS SIBLINGS AND OTHERS WHO LIVE IN THE HOUSEHOLD Name of Siblings relationship with client Age Gender Lives Quality of

______________________ ___ F ___ M ___ good ______________________ ___ F ___ M ___ good ______________________ ___ F ___ M ___ good ______________________ ___ F ___ M ___ good

___ home___ away

___ poor ___ average

___ home___ away

___ poor ___ average

___ home___ away

___ poor ___ average

___ home___ away

___ poor ___ average

Others living in the household Name relationship with client Age Gender Relationship Quality of

______________________ ___ F ___ M______________________ ___ poor ___ average ___ good ______________________ ___ F ___ M______________________ ___ poor ___ average ___ good ______________________ ___ F ___ M______________________ ___ poor ___ average ___ good

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
______________________ ___ F ___ M______________________ ___ poor ___ average ___ good

Comments:

FAMILY HEALTH HISTORY Have any of the following diseases occurred among the childs blood relatives (parents, siblings, aunts, uncles, or grandparents)? Check those that apply: ____ Allergies ____ Anemia ____ Asthma disorder ____ Bleeding tendency ____ Blindness ____ Cancer ____ Cerebral palsy ____ Cleft lips ____ Cleft palate ____ Heart diseases ____ High blood pressure ____ Kidney disease ____ Mental illness ____ Migraines ____ Multiple sclerosis ____ Mental retardation ____ Seizures ____ Spina bifida ____ Suicide ____ Other (specify): ____ Deafness ____ Diabetes ____ Glandular problems ____ Muscular dystrophy ____ Nervousness ____ Perceptual motor

Comments about Family Health:

CHILDHOOD/ADOLESCENT HISTORY Pregnancy/Birth Has the childs mother had any occurrences of miscarriages or stillbirths? ___ Yes___ No If Yes, describe: Was the pregnancy with child planned? ___ Yes___ No Mothers age at childs birth:______ Length of pregnancy:

Fathers age at childs birth: ______

This child is number ______ of ______ total children in family (birth order). How many pounds did the mother gain during the pregnancy? ________ While pregnant did the mother smoke? ___ Yes ___ No If Yes, what amount: _____________________ While pregnant did the mother use drugs or alcohol? ___Yes ___ No If Yes, type/amount: While pregnant, did the mother have any medical or emotional difficulties? (e.g., surgery, hypertension, medication) ___ Yes___ No

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
If Yes, describe: Length of labor: _____________Induced: ___ Yes ___ NoCaesarean? ___ Yes ___ No Babys birth weight: _______________ Babys birth length:

Describe any physical or emotional complications with the delivery: ____________________________________________________________________________________________ Describe any complications for the mother or the baby after the birth: ____________________________________________________________________________________________ Length of hospitalization: Mother: __________________Baby :_________________________ Infancy/Toddlerhood Check all that apply: ___ Breast fed ___ Bottle fed Constipation ___ Not cuddly ___ Milk allergies ___ Rashes ___ Cried often ___ Vomiting ___ Colic ___ Rarely cried ___ Diarrhea ___ ___ Overactive

___ Resisted solid food ___ Trouble sleeping ___ Irritable when awakened ___ Lethargic Developmental History Please note the age at which the following behaviors took place: Sat alone: __________________________ Took first steps: _____________________ Spoke words: _______________________ Spoke sentences: ___________________ Weaned: ___________________________ Fed self: ___________________________ Dressed self: Tied shoelaces: Rode two-wheel bike: Toilet trained: Dry during day: Dry during night: ______ slow ______

Compared with others in the family, childs development was: average _____ fast Age for following developments (fill in where applicable) Began puberty: ________________________ Voice change: _________________________ Breast development: ___________________ Menstruation: Convulsions:

Injuries or hospitalization:

Issues that affected childs development (e.g., physical/sexual abuse, inadequate nutrition, neglect, etc.)

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
EDUCATION Current school: _________________________________________ School phone number: Type of school: ___ Public___ Private___ Home schooled___ Other (specify): Grade: ______________Teacher: ________________________ In special education? ___ Yes ___No In gifted program? ___ Yes ___ No If Yes, describe: If Yes, describe: If Yes, describe: School Counselor:

Has child ever been held back in school? ___ Yes ___ No Which subjects does the child enjoy in school? Which subjects does the child dislike in school? What grades does the child usually receive in school?

Have there been any recent changes in the childs grades? ____ Yes ____ No If Yes, describe: Has the child been tested psychologically? ___ Yes ___ No If Yes, describe:

Check the descriptions that specifically relate to your child. Feelings about Schoolwork: ___ Anxious ___ Eager Rebellious ___ Passive ___ No expression ___ Enthusiastic ___ Bored ___ Fearful ___

___ Other (describe): Approach to Schoolwork: ___ Organized ___ Self-directed expected ___ Sloppy assignments ___ Disorganized ___ Cooperative ___ Doesnt complete ___ Industrious ___ No initiative ___ Responsible ___ Refuses ___ Interested ___ Does only what is

___ Other (describe):

Performance in School (Parents Opinion): ___ Satisfactory ___ Under-achiever ___ Over-achiever

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
___ Other (describe):

Childs Peer Relationships: ___ Spontaneous friends ___ Makes friends easily ___ Long-time friends ___ Shares easily ___ Follower ___ Leader ___ Difficulty making

___ Other (describe): Who handles responsibility for your child in the following areas? School: _____________ Health: _____________ Problem behavior: (specify): _____________ If the child is involved in a vocational program or works at a job, please fill in the following: What is the childs attitude toward work? ___ Poor___ Average___ Good___ Excellent Current employer: ___________________________Position: _____________Hours per week: _______ How have the childs grades in school been affected since working? ____ Higher How many previous jobs or placements has the child had? Usual length of employment: _________________ Usual reason for leaving: ___ Lower ___ Same ___ Mother ___ Father ___ Shared ___ Other ___ Mother ___ Father ___ Shared ___ Other (specify): ___ Mother ___ Father ___ Shared ___ Other (specify):

LEISURE/RECREATIONAL Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc.) ActivityHow often now? How often in the past? __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Nutrition Meal How often (times per week) Typical foods eaten Typical amount eaten

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)

Breakfast High Lunch High Dinner High Snacks High Comments:

___ / week

__________________________

___ None ___ Low ___ Med ___

___ / week

___________________________

___ None ___ Low ___ Med ___

___ / week

___________________________

___ None ___ Low ___ Med ___

___ / week

___________________________

___ None ___ Low ___ Med ___

MEDICAL/PHYSICAL HEALTH ___ Abortion ___ Asthma ___ Blackouts ___ Bronchitis ___ Cerebral palsy ___ Chicken pox ___ Congenital problems ___ Croup ___ Diabetes disease ___ Diphtheria ___ Dizziness ___ Earaches ___ Ear infections ___ Eczema ___ Encephalitis ___ Fevers ___ Hay fever ___ Heart trouble ___ Hepatitis ___ Hives ___ Influenza ___ Lead poisoning ___ Measles ___ Meningitis ___ Miscarriage ___ Multiple sclerosis ___ Mumps ___ Muscular dystrophy ___ Nosebleeds ___ Other skin rashes ___ Paralysis ___ Pleurisy ___ Pneumonia ___ Polio ___ Pregnancy ___ Rheumatic fever ___ Scarlet fever ___ Seizures ___ Severe colds ___ Severe head injury ___ Sexually transmitted ___ Thyroid disorders ___ Vision problems ___ Wearing glasses ___ Whooping cough ___ Other __________________

List any current health concerns:

List any recent health or physical changes: ___________________________________________________________________________________

MOST RECENT EXAMINATIONS Type of examination Physical examination Date of most recent visit _____________________ Results ___________________________

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
Dental examination Vision examination Hearing examination _____________________ _____________________ _____________________ Dose Dates ___________________________ ___________________________ ___________________________ Purpose

Current prescribed medications Side effects

____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

Current over-the-counter meds _________________

Dose

Dates

Purpose

Side effects ___________________________________________________________

____________________________________________________________________________ ____________________________________________________________________________ CHEMICAL USE HISTORY Does the child/adolescent use or have a problem with alcohol or drugs? ___ Yes ___ No If Yes, describe: _____________________________________________________________________________ ____________________________________________________________________________________________ COUNSELING/PRIOR TREATMENT HISTORY Information about child/adolescent (past and present): Yes Counseling/Psychiatric Treatment ___ No ____ ____ ____ ____ When ______ ______ ______ ______ Where ___________ ___________ ___________ ___________ Reaction or overall experience __________________ __________________ __________________ __________________

Suicidal thoughts/attempts ___ Drug/alcohol treatment Hospitalizations ___ ___

BEHAVIORAL/EMOTIONAL Please check any of the following that are typical for your child: ___ Affectionate ___ Frustrated easily ___ Aggressive ___ Gambling ___ Sad ___ Selfish

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)
___ Alcohol problems ___ Angry ___ Anxiety ___ Attachment to dolls ___ Avoids adults ___ Bedwetting ___ Blinking, jerking ___ Bizarre behavior ___ Bullies, threatens ___ Careless, reckless ___ Chest pains ___ Clumsy ___ Confident ___ Cooperative ___ Cyber addiction ___ Defiant ___ Depression ___ Destructive ___ Difficulty speaking ___ Dizziness ___ Drug dependence ___ Eating disorder ___ Enthusiastic ___ Excessive masturbation ___ Expects failure ___ Fatigue ___ Fearful ___ Frequent injuries ___ Generous ___ Hallucinations ___ Head banging ___ Heart problems ___ Hopelessness ___ Hurts animals ___ Imaginary friends ___ Impulsive ___ Irritable ___ Lazy ___ Learning problems ___ Lies frequently ___ Listens to reason ___ Loner ___ Low self-esteem ___ Messy ___ Moody ___ Nightmares ___ Obedient ___ Often sick ___ Oppositional ___ Overactive ___ Overweight ___ Panic attacks ___ Phobias ___ Poor appetite ___ Psychiatric problems ___ Quarrels ___ Separation anxiety ___ Sets fires ___ Sexual addiction ___ Sexual acting out ___ Shares ___ Sick often ___ Short attention span ___ Shy, timid ___ Sleeping problems ___ Slow moving ___ Soiling ___ Speech problems ___ Steals ___ Stomachaches ___ Suicidal threats ___ Suicidal attempts ___ Talks back ___ Teeth grinding ___ Thumb sucking ___ Tics or twitching ___ Unsafe behaviors ___ Unusual thinking ___ Weight loss ___ Withdrawn ___ Worries excessively ___ Other: _____________________ _____________________

Please describe any of the above (or other) concerns:

How are problem behaviors generally handled?

What are the familys favorite activities?

What does the child/adolescent do with unstructured time?

Place4 Counseling/Gulf Bend Center Personal History/ Children & Adolescents (under age 18)

Has the child/adolescent experienced death? (friends, family pets, other) ___ Yes ___ No At what age? _____ If Yes, describe the childs/adolescents reaction:

Have there been any significant changes or events in your childs life? (family members, moving, fire, etc.) ___ Yes ___ No If Yes, describe: ___

Any additional information that you believe would assist us in understanding your child/adolescent?

Any additional information that would assist us in understanding current concerns or problems?

What are your goals for the childs therapy?

What family involvement would you like to see in the therapy?

Do you believe the child is suicidal at this time? ___ Yes ___ No If Yes, explain:

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