SOCIAL, PLAY AND RECREATION
Describe the childs recreational interests (if any).
Briefly describe significant relationships (many/few friends, best friend, romantic relationships, etc.)
Caregiver/HOUSEHOLD information:
Who is primary caregiver of the adolescent? |_| Parent |_| Other Relative |_| Guardian |_| OTHER
If other, explain:
Number of household members:
Who lives in the home with the child (parent(s), siblings, others, etc.):
Who lives in the home with the child (parent(s), siblings, others, etc.
Brief description of living arrangements
Are there any custody/visitation arrangements? Please describe.
Describe the childs family, cultural and religious connections.
Mental Health History:
|_| No previous therapy (Skip to next section of form)
|_| Outpatient Treatment
Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
Type of treatment: (Circle all that apply) Individual therapy family therapy group therapy
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
|_| Inpatient Treatment/Psychiatric Hospitalization
Previously hospitalized: |_| Yes |_| No |_| N/A Multiple Hospitalizations: |_| Yes ___________
Dates of treatment: _____________________________________
Reason for treatment: __________________________________
Has the child experienced grief and or loss, or significant trauma? |_| Yes |_| No Explain:
Recent Comments