Child & Adolescent Life History Questionnaire. Moving Forward Counseling, LLC Middlebelt Road, Suite 100-C Farmington Hills, MI 48334

Transcription

1 Child & Adolescent Life History Questionnaire Moving Forward Counseling, LLC Middlebelt Road, Suite 100-C Farmington Hills, MI Please answer these questions to the best of your ability so that I can obtain a comprehensive understanding of you and your life experiences so I may provide the best services pertaining to your individual needs. Please have these forms completed at time of intake. Thank you for your time, efforts, and cooperation. Date: Client Name: Date of Birth: Alternate or Preferred Name: Age: Address: City: State: Zip Code: Primary Phone # (to confirm appts): ( ) _ Circle Type: Home / Cell / Work Secondary Phone #: ( ) Circle Type: Home / Cell / Work May I leave a message on your answering machine? Yes No Check Box (es) if you DO NOT want: Confirmation Calls Any Phone Contact Social Security # / / Marital Status: Sex: Male Female Other Gender Identification: Who referred you to me? Whom should I contact in case of emergency? Name: Relationship? Home #: Work: Address: _ City: State: Zip If needed what is your hospital of choice Family History Family Members Name Relationship Age Quality of Relationship Living With You? 1

2 Who else lives with you other than the people listed above? Current Marital Status Never Married Widowed How Long? Married How Long? Divorced How Long? Separated How Long? Committed Relationship/Living Together How Long? Assessment of Current Relationship? Good Fair Poor Who were you raised by? Were you adopted? YES NO Relationship to parents during childhood? GOOD FAIR POOR Parents Divorced? NO YES Your age at time of divorce? Number of Brothers living: Deceased: Sisters living : Deceased: How many older than you? Which family members are you close to now? _ Please describe the problem that brings you here: When did your problem begin? Please rate the severity of your problem on the scale below: Low High What are your current goals for treatment? SYMPTOMS: Circle the ones that apply to you: 1. Depression 15. Feeling Controlled 32. Food Bingeing 44. Frequent Crying Spells 2. Feeling talked about 16. Purging 33. Mood Swings 45. Drug or medication us 3. Hopelessness 17. Seeing things others don t 34. Yelling or breaking 46. Bedwetting or other elimination problems 4. Relationship Problems 18. Unusual thoughts 35. Hitting 47. Hear voices in my head 5. Relationship Breakup 19. Increased alcohol use 36. Sleeping too much 48. Problems concentrating 6. Loneliness 20. Increased drug use 37. Frequent crying 49. Decreased activities 7. Emptiness 21. Blackouts/memory loss 38. Gambling 50. Decreased self-care 8. Loss of appetite 22. Withdrawal symptoms 39. Spending 51. Feeling of Guilt/Shame 9. Difficulty at school 23. Financial Worries 40. Conflict with peers 52. Change in appetite, weight loss or gain 10. Nightmares 24. Alcohol use 41. Sexual Behavior 53. Attempts to hurt or kill myself 11. Confusion 25. Racing Thoughts 42, Difficulty in social situations 54. Periods of daily sadness lasting more 2 weeks 12. Fear of Dying 26. Difficulty controlling my temper 43. I break things sometimes 55. Thoughts of hurting or kill myself 13. School Problems 27. I worry a lot 44. Feelings of unreality 56. Can t stop remembering upsetting events 14. Sexual Problems 28. I feel tired almost everyday 57. Made myself throw up in order to lose weight 29. Used laxatives or exercise excessively to loss weight 58. I often feel like I am an outsider 30. Worry that something is wrong with my body 59. Frequent arguments with the people I live with 31. I hear voices in my head Comments: Do you have any thoughts now or recently of wishing you were dead? Do you have any thoughts now or recently of harming yourself? Have you ever attempted to commit suicide or seriously harm yourself? NO YES When? Please explain (How, why): Has anyone in your family attempted or commit suicide? NO YES Who? Please explain: 2

3 Have you ever attempted to kill or seriously harm someone else? NO YES Who? Please explain: Have you ever been the victim of physical, sexual, or verbal Abuse? INTERESTS/ACTIVITIES: (Check all that apply to you): Television Read Exercise Music Listening Movies/Videos Write Play Sports Travel/Sight See Video Games Art Watch Sports Outdoor Activities Play Instrument Church Activities Gamble Sing Go to school Crafts Pets Community Center Other Hobbies/ Interests/Activities: How do you relate to other people? Easily Shy Loner Who do socialize with? Family Friends Coworkers Have you recently lost interest in the activities that you normally enjoy? Do you feel you spend enough time on your interests, hobbies (non work activities)? EDUCATION History: What is the highest grade you ve completed in school? Name of School City & State Dates Attended Highest Grade Completed Type of Classes: Regular Learning Disability Emotionally Handicapped Continuation Opportunity Other Did you skip a grade? Yes No Do you repeat a grade? Yes No If yes, explain: Have you had any specific learning difficulties? Yes No If yes explain Have you ever had a tutor or other special help with schoolwork? Yes No If Yes, explain Do you attend school on a regular basis? Yes No If Yes, explain Do you enjoy school? Yes No If Yes, explain Have you ever been expelled or suspended? Yes No If Yes, explain What was the highest grade on your last report card? What was the lowest grade on your last report card? What is your favorite subject? What is your least favorite subject? Do you participate in after school activities? Yes No If Yes, explain How many friends do you have at school? Have you ever had any special testing in school? Yes No If Yes, explain ETHNIC/CULTURAL BACKGROUND: Do you have any ethnic or cultural concerns? RELIGIOUS/SPIRITUAL BACKGROUND Current religious/spiritual involvement/activities? Do you have any religious or spiritual concerns now? SEXUAL/GENDER ISSUES: (Describe any sexual concerns, gender issues, or sexual orientation issues you may have): 3

4 List all therapists you have seen and the dates you saw them: Name Date Seen INPATIENT: Have you been in the hospital or residential treatment for mental health or substance abuse problems? NO YES When: Where? Reason_ Were any of your treatment experiences helped? NO YES Explain: What medications were you prescribed? Which of those medications were helpful? Have any family members been hospitalized for personal or substance abuse problems? NO YES Who, When, Where? Any involvement in self-help support groups such as: AA, NA, Affirmations etc?_ PHYSICAL HEALTH: Circle the numbers of all items that apply to you now or in the past: 1. Prone to accidents 10. Vision Problems 18. Large weight gain 26. Chronic Pain 2. Asthma 11. Speech Problems 19. Large weight loss 27. Injury from abuse 3. Ulcers 12. Hearing Problems 20. Appetite Disturbance 28. Broken bones 4. Seizures 13. Hypoglycemia 21. Sexually Transmitted Disease 29. Stomach Problems 5. Diabetes 14. HIV Positive 22. Cardiac Problems 30. AIDS 6. Irritable bowel 15. Liver Disease 23. Cancer 31. Hepatitis 7. Heart Disease 16. Major Surgery 24. Back problems 32. Thyroid problems 8. Eating Disorders 17. Chronic fatigue 25. Head injury 33 Insomnia 9. Severe headache/migraine Comments/Other: Are you allergic to any medication(s)? NO YES If yes, name What us your height? feet inches What is your weight? pounds Please List All Current Medications/Dosages Name of Doctor First Prescribed? Most Recent Check-Up: Primary Care Physician: Address City, State, Zip Phone Number: Do you want me to notify your physician that you are seeking therapy? Yes No Please list all current or past health problems and any major operations: Current Past 4

5 Circle any of the following words or terms that apply to you: difficulty concentrating dizziness fainting spells heart palpitation feel anxious bowel disturbances fatigue poor appetite feel angry use sedatives suicidal thoughts insomnia argue frequently tremors feel depressed nightmares allergies use drugs unable to relax sexual problems stomach trouble overly ambitious feel tense feel panicky feelings of inferiority difficulty keeping a job memory problems problems at home financial problems uncomfortable with people difficulty making friends excessive sweating unable to have a good time headaches often use aspirin/painkillers increased alcohol use don t like weekends Other : ALCOHOL AND DRUG USAGE Please Complete This Section Even If You Feel Your Usage Is Not A Problem About how often do you drink alcohol? On the days that you drink, about how much do you consume? About how often do you drink more than you planned to? How much are you capable of drinking in one day? Have you ever experienced blackouts (memory lapses) when drinking? NO YES If you used to drink, when did you stop? Why? Do you use any other mood altering chemicals? NO YES If yes, please name: On the days you use mood altering chemicals, about how much do you use? _ Have you ever overdosed? If you used drugs, when did you stop? Why? Do you ever take more of your prescription medication that you are supposed to? NO YES If yes, please explain: Have any family member had an alcohol or drug problem? NO YES If yes, who? Has your drinking or drug usage ever caused you problems in any of the following areas: NO YES If YES, please check. Family Legal Social Behavior Employment Emotional Financial Physical/Medical Does a relative, loved one, friend, court, or employer feel you have an alcohol or drug problem? NO YES Alcohol and Drug Use History How often have you used any of the following substances? Current Use Past Use (Number of days in past month) (Number of days in average month) Alcohol Amphetamines Cocaine Coffee, Cola, Caffeine Hallucinogens Heroin Inhalants Marijuana Muscle Relaxers Nicotine/Cigarettes Opiates Pain/Pills Narcotics Sedatives Xanax 5

6 Other: What are your drugs of preference: Signature of custodial or legal guardian _ Date Printed Name _ Therapist Signature and Credentials Date 6