Child/Adolescent Interview Form Date: ____________
PERSONAL INFORMATION
Name: __________________________________________________________________________
Age: __________ Sex: __________ Birthday: __________
Address: _____________________________________________________________________________
Religion (if applicable):
__________________________________________________________________
Mother’s Name: ______________________________________________________
Address: _____________________________________________________________________________
Date of Birth: _________________________________________________________________________
Religion (if applicable):
__________________________________________________________________
Contact Number/s: ___________________________ E-mail address: ___________________________
Education (highest degree completed): _____________________________________________________
Occupation: _________________ Employer’s Name: ____________ Contact Number:
_______________
Father’s Name:
________________________________________________________________________
Address: _____________________________________________________________________________
Date of Birth: _________________________________________________________________________
Religion (if applicable):
__________________________________________________________________
Contact Number/s: ___________________________ E-mail address: ___________________________
Education (highest degree completed): _____________________________________________________
Occupation: _________________ Employer’s Name: ____________ Contact Number:
_______________
Parent’s Marital Status: ___ Married ___ Divorced ___ Separated ____ Widowed
___ Others (specify): _______________
Are there other relatives or adults living in the same household as you (i.e. stepparent, siblings,
grandparent)? ____Yes ____No
If yes, indicate the following:
Name of person: _________________ Age: _______ Relationship: ________________
Name of person: _________________ Age: _______ Relationship: ________________
Name of person: _________________ Age: _______ Relationship: ________________
Do you have any siblings? ____Yes ____No
If yes, indicate the following:
Name of sibling: _______________________________ Sex: ________ Age: ________
Name of sibling: _______________________________ Sex: ________ Age: ________
Name of sibling: _______________________________ Sex: ________ Age: ________
ACADEMIC INFORMATION
Are you currently attending school? ____Yes ____No
If yes, indicate the following:
Name of school: ___________________________ Current Level of the child: _________________
Have you received any special education assistance? ____Yes ____No
If yes, indicate the following:
Name of school: ______________ Date: ______ Outcome/Comments: _______________________
Name of school: ______________ Date: ______ Outcome/Comments: _______________________
What do you like about school?
___________________________________________________________
What don’t you like about school?
_________________________________________________________
What activities (if any) do you participate in school? ________________________________________
CHILD’S DEVELOPMENT
1. Were there any complications during the pregnancy or delivery of the client? _____Yes ___ No
If yes, please indicate:
____________________________________________________________
2. Did you have any health problems at birth? _____Yes _____ No
If yes, please indicate:
____________________________________________________________
3. Did you experience any developmental delays (i.e., toilet training, walking, talking, etc.,)?
_____Yes ___ No ___ Not sure
If yes, please indicate:
____________________________________________________________
4. Did you experience any kind of abuse (i.e., emotional, physical, or sexual)
_____Yes ____ No ____ Not sure
If yes, please indicate:
____________________________________________________________
CLIENT HISTORY
1. Have you ever received counseling, psychological, alcohol or drug treatment before?
____Yes _____ No
If yes, please indicate the following:
a. Name of clinic/organization the treatment was conducted: ___________________________
b. Approximate date of counselling/treatment: ______________________________________
c. Please provide us an insight on the results of the treatment:
___________________________________________________________________________
___________________________________________________________________________
2. Did you have any previous mental diagnosis: ___Yes ____No
If yes, please indicate:
____________________________________________________________
3. List the name of your primary care physician.
______________________________________________________________________________
______________________________________________________________________________
4. List any current medical illness or health-related concerns.
______________________________________________________________________________
______________________________________________________________________________
5. Indicate any current medications.
______________________________________________________________________________
______________________________________________________________________________
6. List any family history of mental illness or chemical dependency.
______________________________________________________________________________
______________________________________________________________________________
REFERRAL INFORMATION
Referral Source (if there’s any, indicate the following):
Name: ___________________________________ Relationship: _____________________
Purpose of Referral: ________________________________________
CONCERNS ABOUT THE CHILD
1. Whose idea for you to come here?
______________________________________________________________________________
2. How do you feel being here? _____ I’m okay with it ____Not sure ____I’m against it
_____ Others (please specify):
_____________________________
3. Describe the situation/s that is/are happening in your life that brings you here.
______________________________________________________________________________
______________________________________________________________________________
4. How long has this been a problem?
______________________________________________________________________________
______________________________________________________________________________
5. Indicate any other events happened in your life at the onset of the problem?
______________________________________________________________________________
______________________________________________________________________________
6. Overall, how would you rate the impact of the above-mentioned problems with your performance
at school, social interaction, and daily functioning?
(Mildly disruptive) 1 2 3 4 5 6 7 8 9 10 (Severely disruptive)
Kindly describe:
______________________________________________________________________________
______________________________________________________________________________
CURRENT HABITS
Have you experienced any of the following concerns in the last 6 months? Indicate its severity on a
scale of 1-5 from never to always being experienced. Kindly check the column that refers to the
frequency of the symptom.
Never Rarely Sometimes Frequently Always
1 2 3 4 5
Sadness
Sleep Disturbances
Irritability
Decreased enjoyment with
activities
Low self-esteem
Weight loss/gain
Mood swings
Social Withdrawal
Excessive worry or anxious
Restless
Difficulty concentrating
Difficulty paying attention
Difficulty organizing
Fidgeting
Anger Issues
Bully others
Abuse others
Physically aggressive
Verbally aggressive
Threatens to harm self/others
Hallucinations
Slowed movements
Feelings of detachment from
reality
Feelings of being watched by
others
Drug use
Alcohol use
Trauma flashbacks
Obsessive thoughts
Panic attacks
Are there any problems you are concern about? If yes, please indicate and describe below:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
RELATIONSHIPS
Kindly describe your relationship with the following, if applicable:
a. Biological Mother:
___________________________________________________________________________
b. Biological Father:
___________________________________________________________________________
c. Step-parents:
___________________________________________________________________________
d. Legal guardians:
___________________________________________________________________________
e. Siblings:
___________________________________________________________________________
f. Extended family:
___________________________________________________________________________
g. Classmates:
___________________________________________________________________________
h. Friends:
___________________________________________________________________________
Others (Please specify):
_____________________________________________________________________________________
_____________________________________________________________________________________
STRESSFUL LIFE EVENTS
Kindly describe any significant or stressful life events that you have been experiencing in terms of the
following, if applicable:
a. School Adjustments: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
b. Abuse: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
c. Bullying: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
d. Academic difficulties: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
e. Self-injuries: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
f. Death or illness of a loved one/pet: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
g. Family problem: ___ N/A ___ Yes (if yes, please describe):
______________________________________________________________________________
______________________________________________________________________________
Others (Please Specify):
_____________________________________________________________________________________
_____________________________________________________________________________________
Other Information:
What are your positive attitudes and/or strengths? What attitude/s and activities helped you solved
problems in the past?
_____________________________________________________________________________________
_____________________________________________________________________________________
What are your interests/hobbies?
_____________________________________________________________________________________
_____________________________________________________________________________________
What do you think are your difficulties/weaknesses?
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you or your family have any religious affiliations, spiritual belief system, or way of life that would be
helpful for us to know about? (if yes, please describe):
_____________________________________________________________________________________
_____________________________________________________________________________________
What are the possible goals that you would like to achieve in this therapy?
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you have any concerns/problems that you want to mention? If there are any, feel free to mention
below:
_____________________________________________________________________________________
_____________________________________________________________________________________
WHAT I THINK AND FEEL
Here are some sentences. You can complete these sentences with your own words. You can cite
examples on how you feel and what you think. You can write anything. There are no wrong or right
answers here. Knowing what you think and feel will let me to get to know you more.
What I like best is
______________________________________________________________________
What I like least is
_____________________________________________________________________
My mother thinks I am
__________________________________________________________________
My father thinks I am
__________________________________________________________________
Other kids think I am
____________________________________________________________________
My mother makes me feel
_______________________________________________________________
My father makes me feel
________________________________________________________________
My siblings make me feel
________________________________________________________________
I feel like I am
_________________________________________________________________________
When others correct me, I
_______________________________________________________________
When I have a difficult task to do, I
________________________________________________________
Most of the time, I feel
_________________________________________________________________
I feel happy when
______________________________________________________________________
I feel upset when
______________________________________________________________________
I feel angry when
______________________________________________________________________
* From Merrell (2008b). Copyright 2008 by The Guilford Press.
I, ______________________ have provided voluntarily and willingly all of the above-mentioned
information. All information is intended to be used solely for the course of the treatment. I give my
consent to use this information in the course of the therapeutic process. All information provided are all
correct and aligned with all of my other existing records in my affiliations. I should be informed of any
possible use of the provided information outside this therapy.
Name of the client: _______________________________ Signature: _____________Date: __________
Name of parent/legal guardian: _____________________ Signature: ____________ Date: __________
