Janet M. Kinney   2911 S A.W. Grimes Blvd STE 750, Pflugerville, TX 78660                                                 512-983-6875                                                                                                                                                

Adolescent / Child History Form

PARENT/GUARDIAN INFORMATION

Name:    _______________________________________________               

Date:      _____________________

Address:____________________________________________________                

SSN:      _____________________ DOB:  _________________                     

Phone:   __________________________Cell:_____________________

For confidentiality, when and where do you prefer to be reached?__________

Marital Status:  S____ M____ Sep. ____  D____W____  Date of Current Marriage/ Separation_________  Number of Marriages _____

Child(ren)’s Names ____________________________________

Date of Birth____________________M_____ F_____

Child(ren)’s Names ____________________________________

Date of Birth____________________M_____ F_____

Child(ren)’s Names ____________________________________

Date of Birth____________________M_____ F_____

Child(ren)’s Names ____________________________________

Date of Birth____________________M_____ F_____                         

Occupation___________________________________________

Name of other custodial parent _____________________________

phone _________________

Do you have consent from the other custodial parent for treatment of said child? Y_____ N______

If no, this will be required before counseling may begin.

How much contact does the child have with his/her non-custodial parent?________________

CHILD INFORMATION

Name____________________________________________________

Date of Birth _____________________   SSN____________________

The child is currently living with; _______________________________

School  ___________________________Grade _________________

Extracurricular activities/ interests ______________________________

Medical History

How would you rate your child’s current physical health?  

Excellent __Good__Fair___Poor__

Is the child complaining of any physical problems? (headaches, stomach aches….)__________________________________________________

Previous hospitalizations for medical reasons:   Date:________________ Reason:_________________________________________________

Please list any medical conditions or learning disabilities:______________

Problem Assessment

What has led you to seek counseling at this time:______________________

___________________________________________________________

When did these problems develop:_______________________________

_________________________________________________________

What do you hope to gain from counseling?________________________

_________________________________________________________

Has the child had any previous counseling? ________ If yes, when?______

For what reason____________________By whom?_________________

Has the child been diagnosed with or treated for any type of mental or behavioral disorder? _______  If yes, what?________________________

Has anyone in the child’s family ever been diagnosed with or treated for a mental or behavioral disorder? ______  If yes, explain: ______________

________________________________________________________

Symptoms and Specific Problem Areas: (Please check any that are currently a problem)

___     Adoption                    

___     Depression                

 ___    Legal issues

 ___    Religion/Faith issues  

 ___    Divorce                   

___     Loneliness

 ___    Separation                

___     Loss of appetite

 ___    Eating too much or too little  

___     Anxiety                           

___     Family issues                      

 ___    Anger                                 

 ___    Envy/Jealousy              

  ___   Loss of control         

 ___    Loss of concentration                

 ___    Fear              

___     Apathy                           

___     Conflict with Parents                  

___     Loss of energy                             

 ___    Bitterness/resentment

___     Poor  memory                

___     Child abuse                    

___     Sleep problems                  

  ___   Forgiveness                       

 ___    Loss of temper                        

 ___    Frustration                     

 ___    Loss of trust                

___     Suicidal thoughts

___     Discipline         

 ___    Guilt                                

___     Self-esteem                          

___     Honesty

___     School                                       

 ___    Health/medical              

___     Rejection                                            

 ___    Communication

  ___   Rebellion                                  

___     Panic attacks                                 

 ___    Withdrawal                          

___     PMS/hormones                        

 ___    Violence/rage                                           

___     Physical abuse                   

___     Worry                                   

___     Confusion    

 ___    Death of loved one                  

___    Crying spells                                 

___    Hyperactivity                      

___    Picking Fights

___    Separation from family          

 ___   Nightmares                      

___    Temper tantrums                 

___    Lack of confidence

___    Difficulty making or keeping friends                                   

___    Loss of interest in usual activities            

___    other (explain)

Substance Use (Adolescent)

Do you use alcohol or drugs? ___ Alcohol ___ Drugs   ___ both ___ I don’t use alcohol or drugs

If you use alcohol or drugs, how often do you use them?

   ___ Every day  ___ Several times per week      ___ Several times per month

 ___ Once or twice a month    ___ Several times per year   ___ Once a year

               Other (explain) _____________________________

Have you ever felt you should cut down on your alcohol, prescription drugs or other drug use?  ___ Yes ___ No

Has a friend or relative discussed concerns about your use?     __ Yes__ No

Have you had to take a drink or use a drug the next day to steady your nerves?            ___ Yes___ No

Are you a recovering/ recovered alcoholic or drug addict?    ___ Yes___ No

Is there a history of problems with alcohol or drug use in your family?           ___ Yes    ___ No

Religious/Cultural Factors

Are spiritual or religious issues important to you?  ___ Yes       ___ No

What is your religion? _____________________   

Name of Church ______________________

How important is your religion to you? ___Not at all  ___Slightly important ____Important  ___Very important

Describe how you feel about your spiritual life: 

___ Very happy   ___ Happy   ___ Ok   ___ Unhappy   ___ Very Unhappy ___N/A

Please list any issues that are important or may have affected you in regard to religion or cultural background

____________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________

Other Relevant Information: ______________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________

Child’s Name (please print)  ___________________________________

Parent/ Guardian Name (please print)____________________________

________________________________________________________

Parent/ Guardian Signature                                                                                                          Date

     _________________________________________________ _______

     Janet M. Kinney, Ph. D.                                                 Date