MINOR CLIENT HISTORY
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- Brice Dalton
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1 MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION COMMENT(S) 1) 2) 3) 4) 5) 6) 7) Were they adopted? If yes, what age? Did their parents ever divorce? If yes, what age? Were they ever in foster or residential care? If yes, what age? Have they ever experienced death of someone close? Please indicate if your child / teen or a close family member experienced one or more of the following: EXPERIENCE CHILD OTHER RELATIONSHIP COMMENT(S) Emotional Abuse Physical Abuse Sexual Abuse Domestic Violence Neglect Substance Abuse Serious Illness Accident / Injury Crime Victimization Financial Problems Military Combat Homelessness Discrimination School / Workplace Bullying Head Injury / Concussion Other:
2 The Mauriello Group Page 2 of 7 Please describe any relevant or important information regarding your ethnic / cultural background: Do you have any specific ethnic / cultural concerns? Religious / spiritual background: Current religious / spiritual activity: Do you have any spiritual concerns now? Please list any of your child s or teen s relevant or important interests / activities / hobbies: Do they believe they have enough time for their interests or non-work activity? EDUCATIONAL HISTORY: Please list all of the schools your child / teen has attended, starting with the most current or recent: DATES ATTENDED SCHOOL NAME GRADES / GPA GRADUATE? ANY CONCERNS? List any special education placements: List any suspensions/expulsions: List any future school plans: List any learning disabilities: List any educational concerns: EMPLOYMENT HISTORY: Check One: Full-time Part-time Unemployed Retired Other: Please list all of the jobs your child / teen has held, starting with the most current or recent: DATES EMPLOYED EMPLOYER JOB TITLE REASON FOR LEAVING
3 The Mauriello Group Page 3 of 7 Are they looking for work or new job now? N/A Do they have any employment problems now? N/A Have they ever been fired? N/A Do they have any military experience? N/A Branch: Current/Highest Rank: Discharge : Type of Discharge: LEGAL HISTORY: Please list and describe any current or past arrests, court appearances, or other legal concerns your for child or teen: ARREST DATE CHARGE CONVICTED? SENTENCE Are they currently on Probation? If yes, end date: Are they currently on Parole? If yes, end date: Are they involved in any lawsuits? If yes, describe: Any upcoming court dates? If yes, describe: Are parents currently involved in divorce proceedings? Are parents currently involved in custody proceedings? If yes to any above, describe outstanding legal concerns: MENTAL HEALTH & PHYSICAL HEALTH TREATMENT HISTORY: Have they ever been HOSPITALIZED in a psychiatric hospital? DATES OF ADMISSION HOSPITAL REASON FOR ADMISSION
4 The Mauriello Group Page 4 of 7 Have they received any OUTPATIENT counseling or psychotherapy? DATES OF TREATMENT LOCATION / AGENCY REASON FOR TREATMENT Have they ever been involved in any SELF-HELP or SUPPORT GROUPS? (e.g., Alcoholics Anonymous, Al-Anon, Alateen, etc.) DATES OF INVOLVEMENT GROUP REASON FOR INVOLVEMENT Please list any medications, including psychiatric meds: NAME OF MEDICATION PRESCRIBER REASON Did they previously take any previous psychiatric medications at any time? YES If yes, please describe what and when: NO Please check any of the following concerns that apply to your child/teen now or within the past: Depression Increased alcohol use Nervous/Anxious Mood swings Increased drug usage Panic attacks Hopelessness Blackouts/memory loss Poor concentration Guilt/shame Withdrawal symptoms Confusion Loneliness Target of bullies Disorganized Loss of appetite Bullies/teases others Racing thoughts Overeating/bingeing Gambling Fear of dying Sleep disturbance Poor impulse control Job stress Nightmares Poor anger control Decreased activity Thoughts of harming self Yelling at others Not seeing friends Thoughts of harming others Hitting others School problems Suicide attempts/injuries Breaking objects Sexual problems Cutting Feeling controlled Obsessions/Compulsions Hearing voices Feeling suspicious Autism/Asperger s Seeing things others do not Pessimism Developmental delays Unusual thoughts Phobias/Fears Traumatic Brain Injury Other: Other: Other:
5 The Mauriello Group Page 5 of 7 Please explain any checked items: Have they ever attempted to commit SUICIDE or serious self-harm? If yes: How many times? When? Method(s) of Attempt(s): Has anyone in your family attempted suicide? If yes, who? Has anyone in your family committed suicide? If yes, who? Does your child or teen have any current medical problems? If yes, please list and describe below: Does your child or teen have any history of major medical interventions or surgery? If yes, please list and describe below: Does your child or teen have any history of head injury or traumatic brain injury? If yes, please list when and how: Does your child or teen have any history of loss of consciousness? If yes, please list when and how: ALCOHOL AND DRUG HISTORY: Please list and describe any substance abuse and/or substance treatment history for your child or teen. During the last 12 months Did they ever experience blackouts (i.e., memory lapses) when drinking? Did they ever drink more than you planned to drink? Did they use larger amounts of substances or use them for a longer time than they planned or intended? Did they try to cut down on their substance use, but were unable to do it? Did they spend a lot of time getting substances, using them, or recovering from their use? Did they get so high or sick from using substances that it kept them from doing work, going to school, or other responsibilities? Did they get so high or sick from substances that it caused an accident or put them or others in danger?
6 The Mauriello Group Page 6 of 7 Did they spend less time at work, school, or with friends so that they could use substances? Did their substance use cause emotional or psychological problems? Did their substance use cause problems with family, friends, work, or police? Did their substance use cause physical health or medical problems? Did they increase the amount of a substance so that they could get the same effect? Did they ever keep using a substance to avoid withdrawal symptoms or keep from getting sick? Did they get sick or have withdrawal symptoms when they quit or missed taking a substance? Have they ever experienced an overdose? Has anyone ever commented or been concerned about their drinking or drug use? Has drinking or drug use ever caused problems for them in any of the following areas? Family Employment Legal Emotional Social Financial Behavior Physical Please complete the following chart regarding any substance use by your child in the past 12 months: How often did you use each drug in the past 12 months? Age of 1 st TYPE OF DRUG Only a 1 to 3 times 1 to 5 times Almost use (if Never few times per month per week daily applicable) Caffeine Nicotine/Tobacco Alcohol Marijuana Cocaine (powder) Cocaine (crack) Heroin Methadone Suboxone Pain Medication Ecstasy/MDMA Muscle Relaxers Anti-anxiety meds Inhalants PCP LSD (Meth)amphetamine Sleeping pills Diet Pills Steroids
7 The Mauriello Group Page 7 of 7 Have they ever received any INPATIENT alcohol or drug treatment? If yes, where/when: Have they ever received any OUTPATIENT alcohol or drug treatment? If yes, where/when: Has any family member or loved one ever had a drinking or drug problem? If yes, please describe who / what problem(s): Any other relevant information that you believe is important to your child s or teen s treatment: I verify the above information is true and complete to the best of my knowledge. I understand that any withholding of information, omissions, or misinformation may affect the course of my and/or child s response to any treatment. I agree to inform my healthcare provider(s) of any relevant and/or significant changes as they occur throughout my and/or my child s course of treatment. Client Signature (if 14 or older) Client Representative Signature (if under 18) Client Representative Signature (if under 18) Healthcare Provider
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