Client History Packet for Minor (11-17 years old)
Please complete the following form.  Responses will be viewed by the minor's clinician.
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Email *
Date *
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Time *
Time
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Who is completing this document? *
Client's Name *
Parent(s)/Guardians(s) *
Date of Birth *
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Gender (Please include preferred pronouns) *
How did you hear about Theraplace? *
Name of Primary Care Physician and Clinic *
Do you give permission for ongoing regular updates to be provided to your Primary Care Physician? *
Primary reason(s) for seeking services *
Which school does the child attend? *
Name of teacher(s) *
Current grade *
Does the child have any special programming (ex. Speech, OT, 504, IEP, Accelerated Classes)? *
Additional Information Relating to Education or Employment (ex. change in school, homeschooling program, part time job, volunteer, etc). *
Living Situation (Please check all that apply) *
Required
With whom does the child live? List people, and pets if applicable. *
How important are spiritual or religious beliefs to the child? *
Is the child affiliated with a spiritual or religious group? If yes, which one? Type "no" if they are not affiliated with a spiritual or religious group. *
Would they like spiritual or religious beliefs incorporated into counseling? *
To which cultural or ethnic group does the child belong (Ex. Caucasian, African American, Native American, Hispanic, Somali, etc.)? *
Are they experiencing any problems due to culture or ethnicity? If yes, please describe. Type "no" if they are not experiencing any problems due to culture or ethnicity. *
Other cultural/ethnic information:
Describe areas of interest or hobbies (ex. reading, crafts, sports, outdoor activities). *
Describe the child's strengths and resources.  What do they do well?  Who do they consider supportive (pet, family, friend, therapist)? Which areas of their life are stable? *
Medical/Physical Health - Please check all that apply. *
Required
Please describe any recent changes in their physical health.  Type "none" if no recent changes have occurred. *
Does the child exercise? If yes, please describe what kind of exercise, how many days per week and how much time each day.  Type "no" if they do not exercise. *
Did the child's mother experience any complications during the pregnancy or birth?  If yes, please explain.  Type "no" if there were no complications. *
Please describe family medical history (ex. history of cancer, diabetes, high blood pressure, etc.). *
Please list currently prescribed medication, including name of prescribing physician.  Indicate if they experience any side effects from currently prescribed medication.  Type "none" if they are not currently prescribed medication. *
Please list any current over-the-counter medication (ie. medication that does not require a prescription from a physician), including vitamins or herbal supplements.  Indicate if they experience any side effects from prescribed medication.  Type "none" if they are not taking over-the-counter medication. *
Please list past prescribed medication, including name of prescribing physician.  Indicate if they experienced any side effects from prescribed medication.  Type "none" if they have not been prescribed medication. *
Are they allergic to medication or drugs?  If yes, please describe.  Type "no" if they have no allergies to medication or drugs. *
Please describe any legal information you would like the clinician to know (ex. custody arrangement, court case, etc.). *
Chemical Use History - Check any that the child has used in the past or currently uses.
Used within past 7 days
Used within past 30 days
Used within past 90 days
Used within past 6 months
Used within past year
Used within past 5 years
Used in past, more than 5 years ago
Alcohol
Barbiturates
Cocaine
Ecstasy
Heroin
LSD or Hallucinogens
Marijuana
Methadone
Methamphetamine
Pain killers (not as prescribed)
Stimulants (pills)
Tranquilizer/sleeping pills
Other
Does anyone in the child's family have past or present substance use?  If yes, please indicate which substance(s) and the family member's relationship to the child.  Type "no" if no family members have a history of substance use. *
Development *
Developmental milestones met on time
Developmental delay
Social/Emotional
Cognitive (learning/thinking/problem-solving)
Language/Communication
Movement/Physical
Additional information regarding the child's development (ex. early intervention services utilized).
Sexual orientation
Maltreatment or Abuse - Please check all that apply. *
Required
Childhood Maltreatment or Abuse - Additional information you would like your clinician to know.
Please list immediate family members, including whether they are living or deceased, and approximate ages (ex. parent, sibling, step parent, grandparent). *
Parental Information - Please check all that apply. *
Required
Current Symptoms - Please check any behaviors and symptoms that you experience. *
Required
Briefly discuss how the above symptoms affect the child's functioning at home, school, in the community or socially. *
History of symptoms.  Please describe when the child's symptoms started, when they worsen or improve, etc. *
Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *
0 (none/great)
1
2
3
4
5
6
7
8
9
10 (Severe/poor)
Sadness
Suicidal thoughts
Anxiety
Frustration/anger
Symptom Scaling Questionnaire - Circle one number between 0 and 10 to describe each category. *
0 (poor)
1
2
3
4
5
6
7
8
9
10 (great)
Sleep
Interest/pleasure in life
Appetite
Motivation
Concentration
Energy level
Overall life satisfaction
School satisfaction
Relationship with friends
Relationship with family
Does the child endorse suicidal thoughts or behavior? *
Please describe any history of suicidal ideation or self harm.  Type "none" if they have not experienced suicidal ideation or self harm. *
History of Treatment - Please check all that apply. *
Required
Please list any previous mental health diagnoses.  Type "none" if they have never received a mental health diagnosis. *
History of Treatment for Family Members- Please check all that apply. *
Required
Please list any previous mental health diagnoses for Family Members.  Type "none" if family members have never received a mental health diagnosis. *
Strengths and DIfficulties Questionnaire - Please answer based on the child's behavior over the last 6 months *
Not True
Somewhat True
Certainly True
Considerate of other people's feelings
Restless, overactive, cannot stay still for long
Often complains of headaches, stomachaches or sickness
Shares readily with other young people, for example toys, treats, pencils.
Often loses temper.
Rather solitary. Prefers to play alone.
Generally well behaved, usually does what adults request.
Many worries or often seems worried.
Helpful if someone is hurt, upset or feeling ill.
Constantly fidgeting or squirming.
Has at least one good friend.
Often fights with other children or bullies them.
Often unhappy, depressed or tearful.
Generally liked by other children.
Easily distracted, concentration wanders.
Nervous or clingy in new situations, easily loses confidence.
Kind to younger children.
Often lies or cheats.
Picked on or bullied by other children.
Often volunteers to help others (parents, teachers, other children).
Thinks things out before acting.
Steals from home, school or elsewhere.
Gets along better with adults than with other young people.
Many fears, easily scared.
Good attention span. Sees chores or homework through to the end.
Strengths and DIfficulties Questionnaire - Overall, do you think the child has difficulties in any of the following areas: emotions, concentration, behavior or being able to get along with other people? *
Strengths and DIfficulties Questionnaire - How long have these difficulties been present? *
Strengths and DIfficulties Questionnaire *
Not at all
A little
A medium amount
A great deal
Do the difficulties upset or distress the child?
Do the difficulties interfere with the child'd home life?
Do the difficulties interfere with the child's friendships?
Do the difficulties interfere with the child's classroom learning?
Do the difficulties interfere with the child's leisure activities?
Do the difficulties put a burden on you or your family as a whole?
Strengths and DIfficulties Questionnaire *
No
A little
A lot
Over the last 6 months, have the child's teachers complained of fidgetiness, restlessness or overactivity?
Over the last 6 months, have the child's teachers complained of poor concentration or being easily distracted?
Over the last 6 months, have the child's teachers complained of acting without thinking, frequently butting in, or not waiting their turn?
DSM V Severity Measure for Depression - During the PAST 7 DAYS, the child has... *
0 (0 days)
1 (1-3 days)
2 (4-6 days)
3 (7 days)
Had little interest or pleasure in doing things
Felt down, depressed or hopeless
Had trouble falling or staying asleep, or sleeping too much
Felt tired or had little energy
Had poor appetite or overeating
Felt bad about myself - or that I am a failure or have let myself or my family down
Had trouble concentrating on things
Moved or spoken so slowly that other people could have noticed - or the opposite - been so fidgety or restless that I have been moving around a lot more than usual
Had thoughts that I would be better off dead or of hurting myself in some way
DSM V Severity Measure for Generalized Anxiety Disorder - During the PAST 7 DAYS, the child has... *
0 (0 days)
1 (1-2 days)
2 (3-4 days)
3 (5-6 days)
4 (7 days)
Felt moments of sudden terror, fear or fright
Felt anxious, worried or nervous
Had thoughts of bad things happening, such as family tragedy, ill health, loss of a job or accidents
Felt a racing heart, sweaty, trouble breathing, faint or shaky
Felt tense muscles, felt on edge or restless or had trouble relaxing or trouble sleeping
Avoided, or did not approach or enter, situations about which I worry
Left situations early or participated only minimally due to worries
Spent lots of time making decisions, putting off making decisions or preparing for situations, due to worries
Sought reassurance from others due to worries
Needed help to cope with anxiety (ex. alcohol, medication, superstitious objects, other people)
Any additional information that would assist us in understanding your concerns or problems? *
What are your goals/your child's goals for therapy? *
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