Personal Growth

Better Quality of Life

Reduced Stress

Adolescent Questionnaire

  • Date Format: MM slash DD slash YYYY
  • All information on this form is considered strictly confidential within the guidelines of the clinic.
  • Date Format: MM slash DD slash YYYY
  • Please indicate how this has affected the 􏰀child’s ability to function:
  • Symptoms and Issues

  • Symptoms and Issues continued

  • Things You Worry About or Feel Bad About

  • Problems in Your Family that You Are Worried About

  • Background Information

  • NameAgeEducationOccupation 
  • Name of ParentName of Step-parent or Boy/GirlfriendAgeOccupation 
  • Indicate if A (adoptive), H (half), or S (step)
    NameAgeGrade/EducationPhysical/Emotional Health HistoryIndicate if A, H, or S 
  • NameAgeName of 􏰅child’s other parentPhysical/Emotional Health of child 
  • NameAgeRelationship to YouReason in your house 
  • Safety

    Does the child have a history of abuse or trauma?
  • Has you ever experienced:
  • History of Problem

  • Family Interaction

  • Family History/Culture/Beliefs

  • School History

  • Psychological/Mental Health History

  • Clinic or TherapistDates of ServicesReason/Diagnosis 
  • Hospital/ClinicDates of ServicesReason/Diagnosis 
  • Medical History

  • Name of Medication and DosageReason for the MedicationLength of Use 
  • Please indicate if you have or have had:
  • Social History

  • Job History

  • PositionDutiesDates (from-to) 
    (Please list any jobs you have had in the past)
  • Substance Use

  • Please identify current and historic substance use: Alcohol, Tobacco, Illicit Drugs, Misuse of Rx meds, Other
    TypeQuantityFrequencyAge Started & Stopped 
  • Name of Program/ProviderInpatient/OutpatientDates (from-to) 
  • Client Expectations