Adult Client Questionnaire

Note to individual completing this form: if the information in any item is "unknown" or "unavailable at this time," please indicate such and do not just leave items blank

Last Name*

First Name*

Middle Initial

Name Called By

Date of Birth*

Sex:*
Male Female

What is child's current height?

What is child's current weight?

Minor's Social Security Number*

Home Address

City

Zip (+4)

County of Residence

School and current grade

Primary Language*
English Spanish Other

Please bring with you copy of custody or legal guardianship papers if applicable

CONTACT #1 INFORMATION

Last Name*

First Name*

Living with client?
Yes No

Home Phone

Work Phone

Cell Phone

Preferred Phone
Home Work Cell

May we leave a message at your preferred method of contact?
Yes No

CONTACT #2 INFORMATION

Last Name*

First Name*

Living with client?
Yes No

Home Phone

Work Phone

Cell Phone

Preferred Phone
Home Work Cell

May we leave a message at your preferred method of contact?
Yes No

If Contact 1 and Contact 2 are not the biological/adoptive parents' names, what are their names?

Mother

Father

Other adults currently living in the same household as minor:

Other children in the home:

Are there any members of your household receiving services from Child Guidance & Family Solutions? Yes No

PRIMARY INSURANCE INFORMATION: Bring Copy of Current Insurance Card(s)

ID#

Group/Contract #

Policy Holder Name

Policy Holder Birthdate

Relationship to the Minor
Mother Father Step-Parent Other

Policy Holder Address (if different from minor's)

City

State

Zip (+4)

Policy Holder Employer

Policy Holder SSN#

SECONDARY INSURANCE INFORMATION: Bring Copy of Current Insurance Card(s)

ID#

Group/Contract #

Policy Holder Name

Policy Holder Birthdate

Relationship to the Minor
Mother Father Step-Parent Other

Policy Holder Address (if different from minor's)

City

State

Zip (+4)

Policy Holder Employer

Policy Holder SSN#

How many homes, since birth, has your child lived in?

Does your child have siblings, half-siblings, step-siblings, that currently live elsewhere? Yes No

If yes, please provide the following information:

Full Name

Age

CHILD OF:

LIVING WITH:

Mother Father Other

Mother Father On Own Other

Mother Father Other

Mother Father On Own Other

Mother Father Other

Mother Father On Own Other

SCHOOL RELATED INFORMATION

Does the child receive any special education services (e.g. special class placement, tutoring,speech therapy)?
Yes No

If yes, please specify which service(s)?

Has the child ever repeated a grade?
Yes No

If yes, which grade(s)?

Does/did the child attend a preschool program?
Yes No

If yes, please provide the following information:

Special Educational program provided by local public school because of qualifying condition (e.g. children with severe emotional and/or behavioral problems)?
Yes No

If yes, age(s) of child when attended:

Age of child during year(s) attended:

Does the child have a good attitude about going to school?
Yes No

If no, please explain:

Does the child demonstrate behavioral concerns at school?
Yes No

If yes, please explain:

Does the child typically complete their schoolwork?
Yes No

If no, please explain:

Approximately how many days of school did the child miss last year for any reason?

CHILD'S MEDICAL HISTORY

Name of family physician/pediatrician, or medical clinic where child receives medical care

Date of child's last medical examination (for any reason):

Are immunizations complete and up to date?
Yes No

Does the child have any food allergies? (list below)
Yes No

Does the child have other allergies? (list below)
Yes No

If yes, please list and describe reaction:

Other

Please describe any serious illnesses, injuries, operations and/or hospitalizations the child has experienced since birth (Do not include hospitalizations for psychiatric/emotional/behavioral reasons):

Illness, Operation, or Injury

Age of Child at the Time

If hospitalized, name of hospital and city

Illness, Operation, or Injury

Age of Child at the Time

If hospitalized, name of hospital and city

Illness, Operation, or Injury

Age of Child at the Time

If hospitalized, name of hospital and city

Has the child ever been hospitalized for psychiatric/emotional/behavioral reasons?
Yes No

If yes, when and name of hospital

Is the child currently taking any medication of any kind, prescribed or not?
Yes No

If yes, please provide the following information:

Medication Name

Reason for medication

How often each day?

For how long has she/he been taking it?

Medication Name

Reason for medication

How often each day?

For how long has she/he been taking it?

Medication Name

Reason for medication

How often each day?

For how long has she/he been taking it?

Does the child eat a nutritionally adequate diet?
Yes No

If no, what concerns do you have about the child's diet?

Does the child take multiple vitamins?
Yes No

Is the child on a special diet?
Yes No

If yes, what diet and are you comfortable monitoring it?

Does the child eat non-food items (e.g. dirt, chalk, rocks, paint, etc.)?
Yes No

If yes, please explain

Has the child experienced any unplanned or unusual weight loss or weight gain?
Yes No

The following might be considered "unusual" weight loss:
Young children: 2 pounds in 3 months or 5 pounds in 6 months
Teens: 5 pounds in 1 month or 10 pounds in 6 months

If yes, has the child experienced a recent illness or taken medications?
Yes No

If yes, what illness or medications

PREGNANCY AND BIRTH CIRCUMSTANCES

Did the child's mother use any substances during pregnancy?
Yes No

If yes, please explain

Were there stressful events before, during, or right after the pregnancy and birth that were especially difficult for the biological mother (e.g. death of a family member, loss of job, marital conflict)?
Yes No Unsure

If yes, please explain

Were there complications during pregnancy or delivery, or after birth?
Yes No Unsure

If yes, please explain

If your child's birth was premature, how many weeks early was it?

DEVELOPMENTAL HISTORY

What was the child's weight at birth?

Unsure

Did your child reach developmental milestones during a typical range?
Yes No

FAMILY MEDICAL HISTORY

Please check any of the conditions below which apply to a blood relative of your child. Use the appropriate line to indicate whether on the MOTHER's or the FATHER's side and use the name of the relationship relative to the child (e.g. child's aunt, cousin, grandmother, etc.)

Do you have concerns about drug and/or alcohol abuse by anyone in your family, whether living in your household or not (not including the child - this will be responded to later)?
Yes No

If yes, by whom? Please explain

The following legal issues MAY have some effect on how we create a service plan for you and your family. Please answer below.

Is your family currently, or have you in the past, been involved, in any way, with Child Protective Services or other similar agency?
Yes No

If yes, by whom? Please explain

Is your child for who you are seeking help on probation or parole or otherwise under the supervision of the Juvenile Court or Department of Youth Services?
Yes No

If yes, please explain

Has the child for whom you are seeking help currently ever been the subject of a custody dispute?
Yes No

If yes, please explain

Does there exist any Court Order that specifically prohibits either the mother or the father of the child from accessing information in medical records?
Yes No

If yes, please explain

Has your child experienced any recent (past 12 months) stressful life events, such as a death in the family, divorce, parent job loss, move, etc?
Yes No

If yes, please explain

INFORMATION ABOUT THE CHILD

Please tell us the problem(s) with which you would like help and any preferences on how services might be provided:

Please describe the child's strengths and capabilities:

Has your child received mental health treatment?
Yes No

If yes, please list the agencies and/or individuals you have received help from and the time period they were of service to you:

Has your child been cruel to other people or animals?
Yes No

Has your child used alcohol or other substances?
Yes No

Has your child witnessed domestic violence?
Yes No

Has your child experienced a traumatic event?
Yes No

Do you have concerns about your child's choice of friends?
Yes No

Do you approve of your child's activities with his/her friends?
Yes No

Does the child get along well with others?
Yes No

Person completing questionnaire signature

Today's Date

Client Questionnaire (Standard)

MINOR INFORMATION

CONTACT #1 INFORMATION

CONTACT #2 INFORMATION

PRIMARY INSURANCE INFORMATION: Bring Copy of Current Insurance Card(s)

SECONDARY INSURANCE INFORMATION: Bring Copy of Current Insurance Card(s)

SCHOOL RELATED INFORMATION

CHILD'S MEDICAL HISTORY

NUTRITION

PREGNANCY AND BIRTH CIRCUMSTANCES

DEVELOPMENTAL HISTORY

FAMILY MEDICAL HISTORY

LEGAL ISSUES

STRESSFUL EVENTS

INFORMATION ABOUT THE CHILD

OTHER

SOCIAL