Client History - Adolescent (Part 3)

Social Habits

Relationship with parent: (please identify which parent you are referring to: mother______ father________)

Relationship with other parent: (mother _______ father _______)

Relationship with sibling(s):

Peer relationships:

Teacher relationships:

Mental Health History (include immediate and extended family, i.e, aunts, uncles, grandparents)

History of Depression in Family? Yes ( ) No ( )If yes, please explain:

History of Anxiety in Family? Yes ( ) No ( ) If yes, please explain:

History of Bipolar Disorder in Family? Yes ( ) No ( ) If yes, please explain:

History of alcohol and/or drug abuse/dependence in family? Yes ( ) No( ) If yes, please explain:

Significant trauma, loss, and/or family changes that should be noted in the life of the client or family?

Any other important information you may think will be helpful for your child’s therapeutic treatment…

Thank you.