INITIAL QUESTIONAIRE FORM – CHILD OR ADOLESCENT
TODAY’S DATE:
NAME:
DATE OF BIRTH:
PRIMARY LANGUAGE:
ETHNICITY:
NAME OF PARENTS OR GUARDIANS:
PRESENTING PROBLEM - Please describe why you are seeking therapy at this time. List events, behaviors, issues of
concern, physical and/or emotional complaints.
GOALS AND DESIRED OUTCOME OF TREATMENT -
RELEVANT FAMILY HISTORY AND CURRENT LIVING SITUATION - Explain significant events in your child or
adolescent’s life, history of parent’s separation or divorce etc.
FAMILY MEMBERS OR OTHERS IN THE HOME
NAME
AGE
RELATIONSHIP
1.
2.
3.
4.
***Please list any additional members on the reverse side of this page.
Mary E. Rodela, MS., LMFT#42699
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EDUCATION - Last grade completed and name of last school attended.
LEGAL HISTORY - Include child custody, probation, arrests, convictions and/or conservatorship.
SUBSTANCE ABUSE - Please provide history of use. What is currently being used? How much? How often? Do you see
use as a problem? List any legal issues related to this issue.
MEDICAL/HEALTH HISTORY
Date of last physical examination
How is your child or adolescent’s physical health at present? (Check any that apply)
□ Poor
□ Unsatisfactory
□ Satisfactory
□ Good
□ Very good
Please list current major medical or health concerns
List dates of any hospitalizations, surgeries, head traumas, seizures and/or accidents
MEDICATIONS – List by name, dosage and frequency and include name of prescribing doctor
MENTAL HEALTH HISTORY - Has your child or adolescent been in therapy before? If yes, please list treating
clinician’s name, outpatient treatment, diagnoses and any psychiatric hospitalizations.
Have any members of your immediate family (or relatives) experienced difficulties with the following? (Circle any that may
apply and list relationship of family member, e.g., Sibling, Parent, Uncle, etc.):
DIFFICULTY
FAMILY MEMBER
Depression
Yes/No
Bipolar Disorder
Yes/No
Anxiety Disorders
Yes/No
Panic Attacks
Yes/No
Schizophrenia
Yes/No
Suicide
Yes/No
ABUSE - Is domestic violence, physical abuse or sexual abuse present? If yes, please elaborate:
Mary E. Rodela, MS., LMFT#42699
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