CHILD PERSONAL HISTORY FORM

Please complete and submit. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your child.

Child's legal name

Child's name they go by:

First NameLast Name

Child's pronouns:

Other

Date

Gender identity:

Name of person filling out the form

Client DOB

Date

Preferred contact phone #

Relationship to child

Social Security

Alternative phone #

Address

Email

example@example.com

Emergency contact name & phone #

Parent 1's name:

Parent 2's name:

Names of siblings

Seeking the following services:

Primary reason(s) for seeking services:

Other mental health concerns (specify):

Please select

Language(s) spoken at home:

Religious preference, if applicable

Please answer the following questions to the best of your ability:

1. Goals: What are your goals for coming here? Please be as specific as possible.

2. Opinions a: Is there any difference of opinion among different family members over whether problems exist, or what needs to be done? If so, please give us each person’s viewpoint of the problems and solutions.

3. Opinions b: How about others who know your child (i.e., teachers)? Have they noted any problems or differences? What is their view about what needs to be done to address these issues? Is there any difference of opinion between you and the school? If so, please give us their viewpoints as well as yours.

4. Living arrangements: With whom does the child live at this time?

Child expectations: Does the child know why they are coming? If so, what do they know and expect?

6.Marriage: Please tell us about parents’ marital status. Is this the first marriage for both? If there were prior marriages, are there any children from them? Are parents divorced? Remarried? Separated? If divorced, tell us your opinion of the impact of the divorce on the child. Is there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling?

7. Parent 1:

Please tell us about your occupation.

Is parent 1 currently working?

Part time/full time

Name of parent 1's employer

Work phone

Parent 1's education:

Is there anything notable, unusual or stressful about the child’s relationship with the parent 1?

If Yes, please explain:

How is the child disciplined by parent 1?

For what reasons is the child disciplined by parent 1?

8. Parent 2:

Is parent 2 currently working?

Part time/full time?

Name of parent 2's employers:

Work phone:

Parent 2's education:

Is there anything notable, unusual or stressful about the child’s relationship with the parent 2?

If Yes, please explain

How is the child disciplined by parent 2?

For what reasons is the child disciplined by parent 2?

9.Adoption: If your child was adopted, at what age was the adoption? What information do you have about the history of the biological parents and the child’s his tory before the adoption?

10.Brothers and sisters: Tell us any important information about siblings that would help us. Please include quality of the relationship with client.

11. Caregivers: Please tell us about the adults involved with this child on a regular basis.

12. Family Health

Have any of the following diseases occurred among the child’s blood relatives? (parents, siblings, aunts, uncles or grandparents) Check those which apply:

Comments re: family health:

13.Stress: Please tell us about any recent stresses and crises that have occurred in the family in the last few years. For any stress you list, tell us how you think it may have affected your child. (Include a parent who must work unusually long hours in the list of stresses. Also, include any anticipated future stresses

14. Pregnancy: Please tell us about the pregnancy and delivery of this child. Were there any stresses or problems?

15. Early: Please tell us anything significant about this child’s first months of life. What, if anything did you notice was significant in the first year? What about his or her development was different from what you expected?

16. First 18 months: Please share anything you feel is especially notable about the child’s early development during the first 18 months. What about his or her development was different from what you expected?

17. Medical History: Please indicate anything notable about the child’s medical status, including neurological problems and allergies.

List any current health concerns

List any recent health or physical changes:

Current prescribed medications

Rows	Current Prescribed Medications	Dose	Dates	Side Effects	Purpose
Medication 1
Medication 2
Medication 3
Medication 4

Current over the counter medication

Rows	Current over the counter medications	Dose	Dates	Side Effects	Purpose
Medication 1
Medication 2
Medication 3
Medication 4

Pediatrician/Prescriber’s Information:

Name of Pediatrician/Prescriber:

Office Name of Pediatrician/Prescriber:

Pediatrician/Prescriber’s address:

Phone # of Pediatrician/Prescriber:

18. Education:

Current school:

School phone number:

Type of school

Other

Grade:

Teacher:

School counselor:

In special education?

If Yes, describe:

In gifted program?

If Yes, describe

Has child ever been held back in school?

If Yes, describe

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?

Has there been any recent changes in the child's grades?

If Yes, describe

Has the child been tested psychologically?

If Yes, describe

Check the descriptions which specifically relate to your child.

Feelings about school/work

Other (please describe)

Approach to school work:

Other (describe)

Performance in school (parent’s opinion):

Other

Child’s peer relationships:

Who handles responsibility for your child in the following areas?

School

Other

Health

Other

Problem behavior

Other

If the child is involved in a vocational program or works a job, please fill in the following:

What is the child's attitude towards work?

Current employer:

Position:

Hours per week:

How have the child’s 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

19.Counseling/prior treatment history: Please share with us any prior about any prior counseling the child has received. What worked? What did not work?

20. Behavioral/emotional

Please check any of the following that are typical for your child:

21.Leisure/strengths:

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 What are the family’s favorite activities? What does the child/adolescent do with unstructured time? What would you consider your child’s strengths to be?

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

Submit additional records

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Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your child.