Teen and Young Adult Clinical Questionnaire

AUBREY K. EWING PH.D. & ASSOCIATES, P.A. 1230 So. Federal Hwy, Boynton Beach, FL 33435

TEEN & YOUNG ADULT CLINICAL QUESTIONNAIRE

Please answer all of the questions on the following pages as honestly and accurately as you can. Your answers to these questions are private and no one will see them but your counselor (not even parents unless you give permission The information you provide gives us a head-start in understanding how we can be of help.

Your name

Email address we can use to let you know we received this questionnaire

example@example.com

Date of birth

Date

Age

Gender

Grade/year in school

Name of your school

Are you involved in after school or extracurricular activities (sports, karate, dance, etc.)?

If yes, what are your activities?

Do you have a job?

If yes, where do you work?

Parents' (or guardians') names

Briefly describe your everyday life (like where you live, who you live with, if you have any pets, who are the important people in your life, what it's like living in your home, and anything else you want share).

Name all of the people living in your house, their ages, and their relationships to you:

Example: "Jason, brother, age 10; Rick, dad, age 42..."

Whose idea was it for you to come to counseling?

What is the reason for your counseling appointment?

If it was someone else's idea for you to come for counseling, why do you think they wanted you to come?

If you are having bad feelings or thoughts, please describe them in your own words.

What are you most worried might happen if things don't change?

Have you ever had similar thoughts, feelings, or problems before now? If yes, please describe them, when they occurred, and if anything was done about them.

Have you ever seen another professional (counselor, therapist, psychologist, or psychiatrist) for emotional, behavioral, or learning problems?

If yes, do you think it helped?

Have you ever taken medication to help with emotional, behavioral, or learning problems?

If yes, when?

If you are taking medication now and you know what it is, please list the medicines you take. If you don’t know, you can skip this part.

Do you have any medical or physical problems that are currently bothering you or for which you see a doctor. If so, describe them in your own words.

HISTORY OF IMPORTANT LIFE EVENTS AND PROBLEMS

Please place a check in front of all the statements below that apply to you:

Do any of the following statements describe you (check all that fit):

Check the statements below that best describe you and the things you’ve done (check all that apply):

Check the ones below that apply to you:

Have you recently or in the past had a period of time that lasted two weeks or longer when you:

Have you ever had a period of time lasting at least one week when you:

Please check the statements below that describe you most of the time:

During an anxiety attack I (check all that apply—skip if you don’t have anxiety attacks):

Please check all that are true about you:

Please check any below that apply to you:

Sometimes I have had strange thoughts or experiences that I didn’t understand, such as (check the boxes that apply):

Check the box in front of each statement below that describes you:

If there is anything else you want to tell about yourself, your feelings, or about important things happening in your life, please write anything you want in the space below.

Thank you for taking the time to answer these important questions. The information you provided is helpful to your counselor in getting to know you and how to best help you and your family.