Personal Growth Better Quality of Life Reduced Stress Adolescent Questionnaire Date* MM slash DD slash YYYY All information on this form is considered strictly confidential within the guidelines of the clinic.First Name* Last Name* DOB* MM slash DD slash YYYY Age* How did you hear about us? Insurance Friend / Family Web / Social Media Newspaper Other Please describe the reason for this visit to our clinic:How upsetting is this issue for you? (on a scale of 1-10, with 1=not upsetting, 10=most upsetting): Please indicate how this has affected you:HiddenInstructionsPlease indicate how much this bothers you:In Daily Life Not at all Minimally Moderately Significantly/Severely Academically Not at all Minimally Moderately Significantly/Severely Within the Family Not at all Minimally Moderately Significantly/Severely With Friends or Socially Not at all Minimally Moderately Significantly/Severely How long has this been bothering you?What resources do you have to help you work through this issue?Symptoms and IssuesPlease check all that apply Anxious, worried Anger, aggression, or violence Attitude issues Bored Bullying by others Bullying to others Confused Cutting, burning, or hurting yourself Counting or ordering of things Concentration of focus issues Conflicts with adults (parents, teachers, etc.) Conflicts with others (friends, other kids) Crying or tearful Depressed mood Difficulty being alone Disorganized Drug or alcohol issues Easily distracted Easily irritated Fatigued or tired often Fears (monsters, snakes, people, etc.) Guilt feelings/shame Hyperactive Impulsive Legal issues Living arrangement issues Lying frequently Lonely Money issues Mood swings Motivation reduced or absent Overly worried about germs, organization Panic attacks Perfectionism Physical problems (stomach, head) Self-esteem low Sexual identity concerns Sexual issues School or employment issues Shy or uneasy around others Unassertive Unwanted behaviors or thoughts Withdrawn or alone too much Symptoms and Issues continuedEnergy Levels Too much energy Too little energy Sleep Problems Trouble falling asleep Trouble staying asleep Trouble sleeping too much/too little Eating Habits Binging (eating much more than is needed, or is normal, in a specific time period) Purging (making yourself vomit after eating) Restricting (not eating enough or not eating at all) Overeating (consistently, over time) Using laxatives to control weight Weight Change Increase Decrease Please describe:Behavior Problems At Home At School/After School At Work With Friends/In social settings Things You Worry About or Feel Bad AboutCheck all that apply Being popular Being left out Being bullied Being excluded Being sick a lot Being criticized by others Being suspicious of others Being take advantage of by friends Being involved with pornography Being uncomfortable with the opposite sex Conflicts with brothers/sisters Conflict with parents/step parents Feeling used or pressure to have sex Feeling pressured to do something against your will Getting or being pregnant Getting angry a lot Getting in fights a lot Arguing or competing with others too much Trying to get your way most of the time Thinking your are right all the time Having trouble living up to others' expectations Trying to please everyone Upsetting someone if you say "no" to them Your brother/sister Your parents Your friends Your appearance Your grades Your family Yourself Money problems Not having enough close friends Not knowing enough about sex Not fitting in with others Others putting you down Others having a bad opinion of you Problems with boyfriend/girlfriend Same sex attraction Sex School problems The way you treat other people The way others treat you Thinking about sex too much Other If otherProblems in Your Family that You Are Worried AboutPlease check all that apply Parent is physically sick Parent has an emotional or mental problem Parent has trouble with alcohol or drugs Parents are fighting Parents are divorcing or are divorced Parents are never home or are gone a lot Arguing with step-parent Can't talk to parents/step-parents Don't feel close to family Brother or sister is physically sick Brother or sister has an emotional problem Brother or sister has trouble with alcohol/drugs Family fighting Don't have enough privacy Have too many chores Parents disapprove of clothes, appearance Parents disapprove of friends Parents disapprove of activities, music Don't want to live at home Parents expect too much Parents favor brothers/sisters Feel ignored by my family If yes, please describe:Background InformationHiddenInstructionsPlease fill in your biological parents information below using the Name, Age, Education and Occupation fields.Biological (Birth)/Adoptive Parents:NameAgeEducationOccupation If your biological (birth)/adoptive parents are not together, please fill in the following information for your step- parents or your parent’s boyfriend/girlfriend. Does not apply HiddenInstructionsPlease enter the Name of Parent, Name of Step-parent or Boy/Girlfriend, Age, Occupation in the fields listed below. Name of ParentName of Step-parent or Boy/GirlfriendAgeOccupation If your parents are not together, please describe the custody or visitation arrangements for you. Does not apply Are there any current court proceedings related to custody which involve you? Yes No Does not apply If yes, please describe:If you are adopted or in a foster home, do you see your biological (birth) parents? Yes No Does not apply If yes, please describe how often and where you see them.If no, please share why you do not see your biological parents.Have you ever lived some place other than your home, such as a shelter, a group home, etc.? Yes No Does not apply If yes, please provide details:Have you ever been arrested or placed on probation? Yes No Does not apply If yes, what are the details/specifics of your arrest and/or probation?SiblingsIndicate if A(adoptive), H (half), or S(step) Check if you don't have siblings HiddenInstructionsPlease enter your Siblings Name, Age, Grade, Education and Physical/Emotional Health History into the fields provide below. NameAgeGrade/EducationPhysical/Emotional Health HistoryIndicate if A, H, or S Children Check if you don't have children Number of PregnanciesHiddenInstructionsPlease enter your Children's Name, Age, Name of child's other parent and Physical/Emotional Health of the child into the fields provided below. NameAgeName of child’s other parentPhysical/Emotional Health of child Are both parents involved in your child's life? Yes No Please describe the custody arrangements for your child.You currently live in: Single Family Home Apartment/Condo Townhouse/Condo Mobile Home Other If Other: List any others living in your house and the reason they are in your house (ex: grandparents or step-siblings that live in your house for part of the week). Does Not Apply HiddenInstructionsPlease fill in Name, Age, Relationship to You and Reason in your house in the fields below. Others living in homeNameAgeRelationship to YouReason in your house SafetyDo you have a history of abuse or trauma?HiddenDo you have a history of abuse?Physical Yes No If yes, when and please provide details:Sexual Yes No If yes, when and please provide details:Emotional Yes No If yes, when and please provide details:Verbal Yes No If yes, when and please provide details:Neglect Yes No If yes, when and please provide details:Domestic Abuse Yes No If yes, when and please provide details:Other Yes No If yes, when and please provide details:Have you ever experienced:Have you ever experienced:Suicidal Thoughts Yes No If yes, when and please provide details:Suicidal Attempts Yes No If yes, when and please provide details:Self-harm Yes No If yes, when and please describe the type of harm:History of ProblemPlease describe any changes you’ve had recently, which might be upsetting to you (such as moving, a death in the family, change of schools, birth of a sibling, financial/legal problems, death of a pet, etc.).How have you tried to adjust to the change? Please list things that have worked as well as things that have not worked.Family InteractionWhat do you do together as a family?How does your family express feelings?How often are there conflicts in your family?What are the conflicts typically about?How are these conflicts resolved?Who is typically in charge of discipline in your family?What type of discipline is used in your family?Family History/Culture/BeliefsWhat is your family cultural background (ethnic or racial origin)?What is your family religious background?Please list any cultural or religious traditions that are important to you.What is your primary language?Secondary language(s):What is your sexual orientation?School HistoryWhat school do you go to? What grade are you in? What kind of grades do you usually get? Have there been any changes in your grades recently? Yes No If yes, please describe:What are your favorite classes? What are your least favorite classes? Have you had any problems with friends, other kids, or teachers? Yes No If yes, please describe:Have you ever been given detention, suspended, or expelled from school? Yes No If yes, please describe:Have you been late for school and/or absent from school a lot? Yes No If yes, please describe:Psychological/Mental Health HistoryAre you going, or have you gone, to see the school counselor, school psychologist, or school social worker? Yes No If yes, please provide details:Please list any Counseling or Therapy you have had Does Not Apply HiddenInstructionsPlease enter Clinic of Therapist Name, Dates of Service (from-to), and Reason/Diagnosis in the fields provided.Current or Previous Counseling/TherapyClinic or TherapistDates of ServicesReason/Diagnosis HiddenInstructionsPlease enter Hospital/Clinic, Dates of Service, and Reason/Diagnosis in the fields provided.Please list any previous times you have been in the hospital for your mental healthHospital/ClinicDates of ServicesReason/Diagnosis Medical HistoryWhen was the last time you saw the doctor? Please list any medical problems you’ve had in the last year:Medications N/A HiddenInstructionsPlease list Name of Medication and Dosage, Reason for the medication, Length of time you have taken it in the fields provided below. Name of Medication and DosageReason for the MedicationLength of Use Please indicate if you have or have had:HiddenPlease indicate if you have or have had:Head Injury Yes No If yes, please describe:Concussion Yes No If yes, please describe:Car Accident Yes No If yes, please describe:Surgeries Yes No If yes, please describe:Long Term Illness Yes No If yes, please describe:Seizures Yes No If yes, please describe:Allergies Yes No If yes, please describe:Disabilities Yes No If yes, please describe:Have you ever been injured while playing any sports (football, hockey, soccer, skiing, cheerleading, etc.)? Yes No If yes, please describe:Social HistoryHow many close friends do you have at this time? How often do you see them? Daily 3-5x's a week once a week every other week once a month What recreation, hobbies, or interests do you have?Please list organized activities/sports you are involved in: (such as Girl/Boy Scouts, community baseball, gymnastics, YMCA, etc.):What do you feel you do well?Job HistoryJob History Does Not Apply Do you have a job, either in school or outside school? Yes No Current Employer/Job Position:What typical days and hours do you work?HiddenInstructionsPlease list any jobs you have had in the past. Please fill in Position, Duties, and Dates(from-to) in the provided fields.Previous Jobs:(Please list any jobs you have had in the past)PositionDutiesDates (from-to) Substance Use Check if you have not used drugs or substances HiddenInstructionsPlease identify current and historic substance use: Alcohol, Tobacco, Illicit Drugs, Misuse of Rx meds, Other. Please fill in Substance, Type, Quantity, Frequency and Age Started & Stopped in the provided fields.Please identify current and historic substance use: Alcohol, Tobacco, Illicit Drugs, Misuse Rx meds, OtherSubstanceTypeQuantityFrequencyDates of Use (from / to) Please describe your daily caffeine use (such as coffee, soda, energy drinks, etc.).Have you ever felt you ought to cut down on your drinking or drug use? Yes No Have you had people annoy you by criticizing your drinking or drug use? Yes No Have you felt bad or guilty about your drinking or drug use? Yes No Have you had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover? Yes No Have you experienced negative consequences (DUI, DWI, school failure, etc.) from substance use? Yes No If yes, please provide details:If yes to the above questions, have any of these occurred in the past year? Yes No Please provide details:What is the maximum amount of alcohol/drugs you have had or done on any given day in the past year?Have others who are close to you abused alcohol or drugs? Yes No If yes, please provide details:Are you attending, or have you attended, a self-help group, such as AA, NA, or Alateen? Yes No If yes, please provide details:Chemical Dependency Treatment History Check if you do not have a history of CD treatment HiddenInstructionsPlease fill in Name of Program/Provider, Inpatient/Outpatient, and Dates (from-to) fields below.Name of Program/ProviderInpatient/OutpatientDates (from-to) Client ExpectationsHow do you feel about seeking help at this time?What goals do you have for therapy?What research have you done related to the reason for this visit?How long do you expect to continue therapy?How often would you like to come to therapy?What else do we need to know that we have not asked?NameThis field is for validation purposes and should be left unchanged.
