Personal Growth

Better Quality of Life

Reduced Stress

Adolescent Questionnaire

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  • All information on this form is considered strictly confidential within the guidelines of the clinic.

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  • Please indicate how this has affected you:
  • Hidden
  • 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

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

    Do you have a history of abuse or trauma?
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  • Have you ever experienced:
  • History of Problem

  • Family Interaction

  • Family History/Culture/Beliefs

  • School History

  • Psychological/Mental Health History

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

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

  • Job History

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

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  • SubstanceTypeQuantityFrequencyDates of Use (from / to) 
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  • Name of Program/ProviderInpatient/OutpatientDates (from-to) 
  • Client Expectations

  • This field is for validation purposes and should be left unchanged.