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CA BC Wilder LPR SAG Center BC Washington Huron
If parent is completing, please answer for the adolescent.
: ___________________ Client Name:__________________________________________ Gender:
Age:___________ Birth Date:________________________ With whom do you live?_________________________ Mother’s Full Name________________________________ Father’s Full Name_________________________________ Custody? Alternate Guardian_________________________________ *Did you bring a copy of the most recent court order regarding parenting time and custody?
Why are you seeking services at this time:______________________________________________________________
• Who are you being raised by (check all that apply): Biological mother Biological father
Other: ___________________________________________________________ • How many brothers and sisters do you have? _________________________________________________________ • Briefly describe how you get along with others in your family (ie. Brothers, sisters, parents)_____________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ • Have you ever lived away from your parents? Yes No If yes, explain _______________________________ ______________________________________________________________________________________________ • Is there a history of mental illness in the family? Yes No If yes, who and what kind of problems?_________ ________________________________________________________________________________________________________ • Have any family members committed suicide? No Yes, Who?_____________________________________ • Is there a history of drug and/or alcohol problems in the family? No Yes, who and what kind of substance? ______________________________________________________________________________________________ • Did you witness or experience any physical, sexual or emotional abuse? If yes, please explain. __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ • Please describe the family in which you were raised.____________________________________________________ • Do you identify with a particular ethnic group? Yes No If yes, please name:___________________________ • Do you identify with a particular religious group? Yes No If yes, which one:___________________________ • Have you experienced any difficulties related to your culture, ethnicity or religious affiliation? Yes No If yes, please explain:_____________________________________________________________________________ CLIENT NAME:_____________________________ 2 RELATIONSHIPS:

• If dating, how long with current partner? ____________________________________________
• Are you currently or have you experienced any physical, emotional, or sexual abuse in your relationship(s)? If yes,
please explain. _________________________________________________________________________________ • How many children do you have? ______ What are their ages?___________________________________________ • Do you feel you have enough good friends? Yes No How many do you have?________________________
• How easy do you make friends?_____________________________________________________________________
• What issues with friends are currently concerning you or your child?_______________________________________

• Current school(s) _______________________________________ Grade level _______________________________
• What are your current grades? A’s B’s C’s D’s E’s • Are there any school attendance issues? Yes No If yes, explain.____________________________________ • Have you ever had speech and language therapy? No Yes, where and when?___________________________ ______________________________________________________________________________________________ • Check all that apply regarding your school experience: gifted classes special education school suspensions • Do you have any learning problems? Yes No If yes, what are the problems? ______________________ ______________________________________________________________________________________________ • Do you have a job? Yes No If yes, what is your job?____________________________________________ • Do you have any other sources of income? If yes, please list. Yes No_________________________________ • Do you have any current job issues? Yes No _______________________________________________ • Do you have problems with focus or attentiveness? Yes No • Do you have problems staying seated? Yes No Signed release to communicate with school personnel? CLIENT NAME:_____________________________ 3 DEVELOPMENTAL/MEDICAL HISTORY:
• Length of Mother’s pregnancy for you? premature full-term post-term Birth weight_____________ • Were there any complications during pregnancy and/or during/after birth? (ie. Jaundice, head injury, etc)___________ ______________________________________________________________________________________________ • Did your Mother use substances during pregnancy? Yes No If yes, please list. ___________________ • Developmental Milestones (please list age when accomplished)? Crawl ______ Walk _______ Single word _____ 2 words+ _____ Bladder trained? day_____ night______ Bowel trained? day______ night________ • Has there been a history of bedwetting? Yes No If yes, explain; ____________________________________ • Has there been a history of soiling? Yes No If yes, explain; _______________________________________ • Hearing issues? Yes No If yes, explain_____________________________________________________ • Vision issues? Yes No If yes, explain_____________________________________________________ • Dental issues? Yes No If yes, explain_____________________________________________________ • Medical Primary Care Physician: ________________________________________ Date last seen: _____________ • How do you rate your general health? poor fair average good excellent • Immunizations up to date? Yes No If no, explain?____________________________________________ • What, if any, medical problems do you have (such as asthma, diabetes)?____________________________________ ______________________________________________________________________________________________ • Are you currently taking medications? Yes No If yes, what medications?__________________________ ______________________________________________________________________________________________ • Drug allergies/adverse reactions/side effects___________________________________________________________ _______________________________________________________________________________________ • Do you have any concerns related to your weight?______________________________________________________ • Has your weight change over the last year? No Yes Lost _____lbs. Gained _____lbs. • How many meals do you eat a day?_______Do you have any changes in eating habits/appetite? Yes No If yes, please describe: ____________________________________________________________________________ • Do you currently participate in any type of exercise/physical activity? If yes, please describe: ___________________ ______________________________________________________________________________________________ • Caffeine Use: How many cups, cans or glasses of caffeinated beverages per day do you drink? __________________ • Do you currently use any tobacco products? If yes, describe_______________________________________________ • Have you had any head injuries or loss of consciousness? Yes No If yes, explain:___________________ _______________________________________________________________________________________ • Have you had any surgeries? Yes No If yes, please list dates and what type:________________________ _______________________________________________________________________________________ • Do you or have you ever struggled with eating issues such as binging, purging, compulsive overeating or going days without eating? If yes, please describe.______________________________________________________________ _____________________________________________________________________________________________ CLIENT NAME:_____________________________ 4 PSYCHIATRIC HISTORY:

• Describe your personality (i.e. aggressive, calm, shy, high energy)_________________________________________
• Have you been in counseling before? Yes No If yes, what type and when:___________________________ _______________________________________________________________________________________ • Have you ever been hospitalized for psychiatric reasons? Yes No If yes, where and when:_______________ _______________________________________________________________________________________ • Listed below are a number of categories in which people commonly find some difficulties. Please indicate how you are affected in each area by circling the appropriate number (please circle only one number for each item). SOMEWHAT OF A
Depression (sadness, loss of interest, etc) Anxiety (nervousness, panic, excessive worry) 1 2 3 4 5 Hallucinations (hearing voices/seeing things) 1 2 3 4 5 *Obsessions or compulsions
*Serious trauma
*Explain _________________________________________________________________________________

• Who do you rely on for support? (ie, spouse, parents, coworkers, etc) ___________________________________
CLIENT NAME:_____________________________ 5 BEHAVIOR:
• Do you have concerns about your behavior? Yes No If yes, explain ______________________________
______________________________________________________________________________________________ • Describe any changes in your behavior in the past year___________________________________________________ ______________________________________________________________________________________________ • What disciplinary methods are commonly used and how effective are they? __________________________________ ______________________________________________________________________________________________ • Who usually disciplines you? ______________________________________________________________________ • Are you using illegal substances or do your parents/guardian suspect you of this behavior? Yes No If yes, explain: _______________________________________________________________________________________ Please complete the following regarding your drug/alcohol use history: SUBSTANCES USED/ABUSED
(such as alcohol, marijuana, vicodin, etc)
What is your substance of preference?________________________________________________________________

Please answer the following questions:

I have felt bad or guilty about my use of drugs/alcohol. Family members complain about my drug/alcohol use. My drug/alcohol use has created problems for my family. I lost friends because of my drug/alcohol use. I neglected my family because of my drug/alcohol use. I got in trouble at work/school because of my drug/alcohol use. I got in physical fights while under the influence of drugs/alcohol. • Have you received treatment for a substance abuse problem before? Yes No If yes, explain______________ ______________________________________________________________________________________________ • Were you ever arrested, convicted or placed on probation? Yes No If yes, describe below: Age___________ Offense_____________________________________________________________________ Age___________ Offense_____________________________________________________________________ • Are you currently on Probation/Parole? Yes No If yes, describe and give PO name:_______________ ____________________________________________________________________________________
_________________________________________________________ _____________________________

Parent/Guardian Signature

Source: http://mdcloud.co/Forms/Adolescent%20Assessment.pdf


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