Restorative Psychological LLC 1

Personal History—Children and Adolescents

Client’s name: _______________________ Date:_____________________

Gender: _____ F _____ M Date of birth: _______ Age: ____ Grade in school: ____
Form completed by: _____________________________________
Address: _____________________ City: ___________ State: ____ Zip: _______
Phone (home/mobile): ________________ Work: ________________ Ext: _______

If you need any more space for any of the following questions please use the back of the
sheet.

Primary reason(s) for seeking services:

____ Addictive behaviors ____ Coping ____ Fear/phobias
____ Alcohol/drugs ____ Depression/Anxiety ____ Mental confusion
____ Anger management ____ Hyperactivity ____ Sexual concerns
____ Autism ____ Eating disorder ____ Sleeping problems
____ Other mental health concerns (specify):
______________________________________________________________________________
______________________________________________________________________________

Family History

Parents
With whom does the child live at this time? __________________________________________
Are parent’s divorced or separated? ________________________________________________
If yes, who has legal custody? _____________________________________________________
Were the child’s parents ever married? _____ Yes _____ No
Is there any significant information about the parents’ relationship or treatment toward the child
which might be beneficial in counseling? _____ Yes _____ No
If yes, describe: ________________________________________________________________

Client’s Mother
Name: ______________ Age: ____ Occupation: ______________ __FT __PT
Where employed: __________________ Work phone: ____________________________
Mother’s education: ________________
Is the child currently living with mother? _____ Yes _____ No
_____ Natural parent _____ Step-parent _____ Adoptive parent _____ Foster home
_____ Other (specify): ___________________________________________________________
Is there anything notable, unusual or stressful about the child’s relationship with the mother?
_____ Yes _____ No
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
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How is the child disciplined by the mother? __________________________________________

For what reason is the child disciplined by the mother?
______________________________________________________________________________

Client’s Father
Name: ______________ Age: ____ Occupation: ______________ __FT __PT
Where employed: __________________ Work phone: ____________________________
Father’s education: ________________
Is the child currently living with mother? _____ Yes _____ No
_____ Natural parent _____ Step-parent _____ Adoptive parent _____ Foster home
_____ Other (specify): ___________________________________________________________
Is there anything notable, unusual or stressful about the child’s relationship with the mother?
_____ Yes _____ No
If yes, please explain:
______________________________________________________________________________
______________________________________________________________________________
How is the child disciplined by the mother? __________________________________________
For what reason is the child disciplined by the mother?
______________________________________________________________________________

Client’s Siblings and Others Who Live in the Household

Blended household? Yes___ No ____

Name of siblings Age Gender Lives Quality of

relationship with
the client
_______ F _______home _______poor
_______ M _______away _______average
_____________ _____________ _______good
_______ F _______home _______poor
_______ M _______away _______average
_____________ _____________ _______good
_______ F _______home _______poor
_______ M _______away _______average
_____________ _____________ _______good
_______ F _______home _______poor
_______ M _______away _______average
_____________ _____________ _______good
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Others living in the Age Relationship (e.g. Quality of

household cousin, foster child) relationship with the
client
_______poor
_______average
_____________ _____________ _____________ _______good
_______poor
_______average
_____________ _____________ _____________ _______good
_______poor
_______average
_____________ _____________ _____________ _______good
_______poor
_______average
_____________ _____________ _____________ _______good

If child is on a custody visitation schedule, please describe: ______________________________

______________________________________________________________________________
Members of the family in child’s second home: _______________________________________
______________________________________________________________________________

Family Health History

Have any of the following diseases occurred among the child’s blood relatives (parents, siblings,
aunts, uncles, or grandparents)? Check those which apply:

____ Allergies ____ Deafness ____ Multiple sclerosis

____ Anemia ____ Diabetes ____ Muscular Dystrophy
____ Asthma ____ Glandular problems ____ Nervousness
____ Bleeding tendency ____ Heart disease ____ Perceptual motor disorder
____ Blindness ____ High blood pressure ____ Seizures
____ Cancer ____ Intellectual disability ____ Spinal Bifida
____ Cerebral Palsy ____ Kidney disease ____ Suicide
____ Cleft lips ____ Mental illness ____ Autism
____ Cleft palate ____ Migraines ____ Other (specify below)

Comments re: Family Health:

______________________________________________________________________________
______________________________________________________________________________
Restorative Psychological LLC 4

Childhood/Adolescent History
Pregnancy/Birth
Has the child’s mother had any occurrences of miscarriages or stillborn? _____ Yes _____ No
If yes, describe: ________________________________________________________________
Was the pregnancy with child planned? _____ Yes _____ No Length of pregnancy: ______
Mother’s age at child’s birth: _______ Father’s age at child’s birth: _______
Child number _____ of _____ total children.
How many pounds did the mother gain during the pregnancy? _______
While pregnant did the mother smoke?
_____ Yes _____ No If yes, what amount: _________________________
Did the mother use drugs or alcohol?
_____ Yes _____ No If yes, what type/ amount: ____________________
Prescription medicine during pregnancy? If yes, what? _________________________________
While pregnant, did the mother have any medical or emotional difficulties? (e.g., surgery,
hypertension, medication) _____ Yes _____ No
If yes, describe: ________________________________________________________________
Length of gestation (number of weeks): _________________
Length of labor: __________ Induced: ____Yes ____No Caesarean: ____Yes ____No
Baby’s birth weight: _______ Baby’s birth length: _______
Describe any physical or emotional complications with the delivery:
______________________________________________________________________________
______________________________________________________________________________
Describe any complications for the mother or the baby after the birth:
______________________________________________________________________________
______________________________________________________________________________
Length of hospitalization—Mother: _______ Baby: _______

Infancy/Toddlerhood
Check all which apply:
____ Breast fed ____ Milk allergies ____ Vomiting
____ Bottle fed ____ Rashes ____ Colic
____ Not cuddly ____ Cried often ____ Rarely cried
____ Resisted solid food ____ Trouble sleeping ____ Irritable when awakened
____ Diarrhea ____ Constipation ____ Overreactive
____ Lethargic

Developmental History
Please note the age at which the following behaviors took place:
Sat alone: _______________________ Dressed Self: ________________________
Took 1st steps: ___________________ Tied shoelaces: ______________________
Spoke words: ____________________ Rode two-wheeled bike: _______________
Spoke sentences: _________________ Toilet trained: ________________________
Weaned: ________________________ Dry during day: ______________________
Fed self: ________________________ Dry during night: _____________________
Compared with others in the family, child’s development was: ___slow ___average ___fast
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Age for following developments (fill-in where applicable):

Began puberty: _______________________ Menstruation: _______________________
Voice change: ________________________ Convulsions: ________________________
Breast development: ___________________ Injuries or hospitalization: ______________
Issues that affected child’s development (e.g. physical/sexual abuse, inadequate nutrition,
neglect, etc.):
______________________________________________________________________________
______________________________________________________________________________

Most Recent Examinations

Type of examination Approx. date of most recent visit Results

Physical exam _____________ _____________

Dental exam _____________ _____________

Vision exam _____________ _____________

Hearing exam _____________ _____________

Current Dose Dates Purpose Side effects

prescribed
medications

_____________ _____________ _____________ _____________ _____________

_____________ _____________ _____________ _____________ _____________

_____________ _____________ _____________ _____________ _____________

_____________ _____________ _____________ _____________ _____________

Pediatrician: ______________________________ Office & location: _____________________

Psychiatrist: ______________________________ Office & location: _____________________
Other health specialists managing child: ____________________________________________
____________________________________________
____________________________________________
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Current over the Dose Dates Purpose Side effects

counter
medications

_____________ _____________ _____________ _____________ _____________

_____________ _____________ _____________ _____________ _____________

_____________ _____________ _____________ _____________ _____________

_____________ _____________ _____________ _____________ _____________

Other Services: Provider Frequency Period of Treatment

Early Intervention _______________ ____________ ____________________________
Speech and Language _______________ ____________ ____________________________
Occupational Therapy _______________ ____________ ____________________________
Physical Therapy _______________ ____________ ____________________________

Chemical Use History

Does the child/adolescent use or have a problem with alcohol or drugs? ____Yes ____No
If yes, describe:
______________________________________________________________________________
______________________________________________________________________________

Counseling/ Prior Treatment History

Information about child/adolescent (past/present):

Yes No When Where Reaction or overall

experience

Counseling/Psychiatric
treatment _____ _____ _____________ _________ _______________

Suicidal
thoughts/attempts _____ _____ _____________ _________ _______________

Drug/alcohol treatment _____ _____ _____________ _________ _______________

Hospitalization _____ _____ _____________ _________ _______________

Comments: __________________________________________________________________
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Behavioral/Emotional
____ Affectionate ____ Frustrated easily ____ Sad
____ Aggressive ____ Gambling ____ Selfish
____ Alcohol problems ____ Generous ____ Separation anxiety
____ Angry ____ Hallucinations ____ Sets fires
____ Anxiety ____ Head banging ____ Sexual addiction
____ Attachment to dolls ____ Heart problems ____ Sexual acting out
____ Avoids adults ____ Hopelessness ____ Shares
____ Bedwetting ____ Hurts animals ____ Sick often
____ Blinking/jerking ____ Imaginary friends ____ Short attention span
____ Bizarre behavior ____ Impulsive ____ Shy, timid
____ Bullies, threatens ____ Irritable ____ Sleeping problems
____ Carelessness, reckless ____ Lazy ____ Slow moving
____ Chest pains ____ Learning problems ____ Soiling
____ Clumsy ____ Lies frequently ____ Speech problems
____ Confident ____ Listens to reason ____ Steals
____ Cooperative ____ Loner ____ Stomach aches
____ Cyber addiction ____ Low self-esteem ____ Suicidal attempts
____ Defiant ____ Messy ____ Talks back
____ Depression ____ Moody ____ Teeth grinding
____ Destructive ____ Nightmares ____ Thumb sucking
____ Difficult Speaking ____ Obedient ____ Tics or twitching
____ Dizziness ____ Often sick ____ Unsafe behaviors
____ Drugs dependence ____ Oppositional ____ Unusual thinking
____ Eating disorder ____ Overactive ____ Weight loss
____ Enthusiastic ____ Overweight ____ Withdrawn
____ Excessive masturbation ____ Panic attacks ____ Worries excessively
____ Expects failure ____ Phobias ____ Other:___________
____ Fatigue ____ Poor appetite _____________________
____ Fearful ____ Psychiatric problems _____________________
____ Frequent injuries ____ Quarrels _____________________

Please describe any of the above (or other) concerns:

______________________________________________________________________________
______________________________________________________________________________
How are problem behavior generally handled?
______________________________________________________________________________
______________________________________________________________________________
What are the family’s favorite activities?
______________________________________________________________________________
______________________________________________________________________________
How often does the family eat dinner together? _______________________________________

How many hours does the child spend in entertainment electronics on a weekday? ___________
How many hours does the child spend in entertainment electronics on a weekend? ___________
Restorative Psychological LLC 8

Education

Current school: ___________________ School phone number : ___________________

Gender: _____ Public _____ Private _____ Home schooled _____ Other (specify): _________
Grade: _____ Teacher: ___________________ School counselor: _______________________
In special education? _____ Yes _____ No If yes, describe: _____________________
In gifted program? _____ Yes _____ No If yes, describe: _____________________
Has your child ever been held back in school? _____ Yes _____ No
If yes, describe: ________________________________________________________
Which subjects does the child enjoy in school? ______________________________________
Which subjects does the child dislike in school? ______________________________________
What grades does the child usually receive in school? __________________________________
Have there been any recent changes in the child’s grades? _____ Yes _____ No
If yes, describe: ________________________________________________________
Has the child been tested psychologically? _____ Yes _____ No
If yes, describe: ________________________________________________________

Check the descriptions which specifically relate to your child.

Feelings About Schoolwork:

____ Anxious ____ Eager
____ Passive ____ No expression
____ Enthusiastic ____ Bored
____ Fearful ____ Rebellious
____ Other (describe): ___________________________________________________________

Approach to Schoolwork:
____ Organized ____ Responsible
____ Self-directed ____ Refuses
____ Sloppy ____ Cooperative
____ Industrious ____ Interested
____ No initiative ____ Does only what is expected
____ Disorganized ____ Doesn’t complete assignments
____ Other (describe): ___________________________________________________________

Performance in School (Parent’s Opinion):

____ Satisfactory ____ Underachiever ____ Overachiever
____ Other (describe): ___________________________________________________________

Child’s Peer Relationships:

____ Spontaneous ____ Makes friends easily
____ Follower ____ Long-time friends
____ Leader ____ Shares easily
____ Difficulty making friends ____ Other (describe): _______________________
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Who handles responsibility for your child in the following areas?

School: _____ Mother _____ Father _____ Shared _____ Other (specify): ______
Health: _____ Mother _____ Father _____ Shared _____ Other (specify): ______
Problem Behavior: _____ Mother _____ Father _____ Shared _____ Other (specify): ______

Youth Work
If your adolescent is involved in a vocational program or works a job, please fill in the following:
What is the child’s attitude toward work? ____Poor ____Average ____Good ____Excellent
Current employer: ______________ Position: ______________ Hours per week: ____
How have the child’s grades in school been affected since working ? __Lower __Same __Higher
How many previous jobs or placements has the child had? ______________________________
Usual length of employment: _______________ Usual reason for leaving: _______________

Leisure/Recreational
Describe special areas of interest or hobbies (e.g. art, books, crafts, physical fitness, sports,
outdoor activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities,
scouts, etc.)
Activity How often now? How often in the past?

_____________________ _____________________ _____________________________

_____________________ _____________________ _____________________________

_____________________ _____________________ _____________________________

_____________________ _____________________ _____________________________

Medical/Physical Health History

____ Abortion ____ Hay fever ____ Pneumonia

____ Asthma ____ Heart trouble ____ Polio
____ Blackouts ____ Hepatitis ____ Pregnancy
____ Bronchitis ____ Hives ____ Rheumatic fever
____ Cerebral Palsy ____ Influenza ____ Scarlet fever
____ Chicken Pox ____ Lead poisoning ____ Seizures
____ Congenital problems ____ Measles ____ Severe colds
____ Croup ____ Meningitis ____ Severe head injury
____ Diabetes ____ Miscarriage ____ Sexually transmitted disease
____ Diphtheria ____ Multiple sclerosis ____ Thyroid disorders
____ Dizziness ____ Mumps ____ Vision problems
____ Earaches ____ Muscular Dystrophy ____ Wearing glasses
____ Ear infections ____ Nose bleeds ____ Whooping cough
____ Eczema ____ Other skin rashes ____ Other:_______________
____ Encephalitis ____ Paralysis _________________________
____ Fevers ____ Pleurisy _________________________
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List any current health concerns:

______________________________________________________________________________
______________________________________________________________________________

List any recent health or physical changes:

______________________________________________________________________________
______________________________________________________________________________

Nutrition
Meal How often (times Typical foods eaten Typical
per week) amount
eaten
__No
Breakfast __________/ week _________________________ __Low
__Med
__High

__No
Lunch __________/ week __________________________ __Low
__Med
__High

__No
Dinner __________/ week __________________________ __Low
__Med
__High

__No
Snacks __________/ week __________________________ __Low
__Med
__High
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Social Relationships
Adult-child Relations
Who is the child’s primary attachment figure? ________________________________________

Discipline Procedures
Who handles the discipline? ______________________________________________________

Parenting books/seminars: ________________________________________________________

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What strategies have been implemented to address discipline concerns?

Implementations (please check mark in the next Effective?
column if used)

Verbal reprimands _____ Yes _____ No

Time out (solution) _____ Yes _____ No

Removal of privileges _____ Yes _____ No

Rewards _____ Yes _____ No

Physical punishment _____ Yes _____ No

Acquiescence to child _____ Yes _____ No

Avoidance of child _____ Yes _____ No

Is this an area you like assistance with? Y N

Involvement in Community Activities: (e.g. family attends church, child attends boy scouts,
gymnastics, little league, Sunday school, etc.)
______________________________________________________________________________
______________________________________________________________________________
If so: please describe type of relational interaction.
______________________________________________________________________________
______________________________________________________________________________

Free Time Activities:

What does your child enjoy doing?
______________________________________________________________________________
______________________________________________________________________________
What responsibilities does your child have at home?
______________________________________________________________________________
______________________________________________________________________________

Child’s Strengths
What do you like about your child?
______________________________________________________________________________
______________________________________________________________________________
What are your child’s strengths?
______________________________________________________________________________
______________________________________________________________________________
What are areas in which your child needs to improve?
______________________________________________________________________________
______________________________________________________________________________
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What are the family strengths?

______________________________________________________________________________
______________________________________________________________________________

Peer Relations
Does your child have friend (4+ years)? _____ Yes _____ No
Does your child have a best friend (4+ years)? _____ Yes _____ No
How would you describe your child’s relationships with peers? How does s/he get along with
friends?
______________________________________________________________________________
______________________________________________________________________________
What role does the child have in play—leader, clown, disrupter, sex role?
______________________________________________________________________________
______________________________________________________________________________
If left alone, what would your child do to occupy his/her time?
______________________________________________________________________________
______________________________________________________________________________
Does your child have any behavioral difficulties at school?
Aggression towards peers: ________________________________________________________
Aggression towards teachers:______________________________________________________
Withdrawn/shy:_________________________________________________________________
Anxious: ______________________________________________________________________
No friends: ____________________________________________________________________
Being bullied by others: __________________________________________________________
Has your child ever been held back or suspended? _____ Yes _____ No
If so, why?
________________________________________________________________________
________________________________________________________________________

Trauma History
Does your child have any history of physical abuse or neglect? _____ Yes _____ No
If so, what is known?
________________________________________________________________________
Does your child have nay history of sexual abuse? _____ Yes _____ No
If so, what is known?
________________________________________________________________________
Has your child ever been exposed to domestic violence or community violence? ___ Yes ___ No
Have there been any deaths in the child’s circle of close friends or family? _____ Yes _____ No
Please explain:
________________________________________________________________________
Has any consistent caregiver or close friend moved away? Any noticeable changes in the child’s
behavior immediately following this loss?
______________________________________________________________________________
______________________________________________________________________________

THANK YOU!