Child/Adolescent History Questionnaire — Online Form

Online Form

A parent or caregiver completes this questionnaire before a child or adolescent begins services, giving the therapist a full picture of the child's family, development, health, school, and behavioral history (adolescents ages 12-18 complete the substance use and PHQ-9 sections themselves).

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Child and Contact Information

Child’s Name

Age

Gender

Today’s Date

Date of Birth

Race

Your Name

Your Relationship to Child

Address

Phone

Is it okay to leave a message?

Address (line 2)

Phone

Is it okay to leave a message?

Emergency Contact

Phone

Relationship

Biological Father’s Name

Age

Biological Mother’s Name

Age

Parents’ Current Marital Status

Who has legal custody of the child?

Has your child ever lived with someone other than you?

Primary Household

Name	Relationship to child	Age	Quality of relationship

Secondary Household

If the child lives in more than one household please complete the secondary household information below.

Secondary Household

Name	Relationship to child	Age	Quality of relationship

Reason for Seeking Services

Were you referred to TSA (if yes, who and for what reason)?

What led you to seek our services?

When did this problem begin?

How often does this problem occur?

How severe is the problem now?

On a scale 1 to 10; 1 is the lowest and 10 is highest (Low / Medium / High)

Has this child experienced any of the following (please check)?

Please describe any of the items endorsed above

Family Concerns

Please check if the following pertain to any of the child’s family members

Please describe any of the items endorsed above

Developmental Issues: Prenatal/Birth History

Birth mother used alcohol, tobacco, and/or nonprescription drugs while pregnant

Birth mother was depressed during the pregnancy

Birth mother was under stress or was a victim of abuse during the pregnancy

Birth mother had medical complications during the pregnancy

Birth mother had medical complications during labor and/or delivery

Birth father had health problems or was under stress during pregnancy

Child was oxygen-deprived or had breathing-related problems during/after birth

Child had other significant medical problems at birth

Child’s Early Development (did the child have any of the following before age 3)

Feeding problems

Onset

Sleeping problems

Onset

Colicky or excessively fussy

Onset

Slow in learning to roll over, sit up, crawl, or walk

Onset

Slow in learning to use fingers to pick things up, stack blocks, use crayons, etc.

Onset

Slow in learning to understand the speech of others

Onset

Slow in learning to talk

Onset

Slow in learning self-help skills (eating with a spoon, dressing, brushing teeth)

Onset

Slow in learning colors, numbers, etc.

Onset

Poor social interaction with other children (e.g. would fight often or play alone)

Onset

Weak, inconsistent, or indiscriminant emotional attachment to caregivers

Onset

Excessive emotional attachment to caregivers (clingy, had separation anxiety)

Onset

Failure to seek out caregiver when distressed

Onset

Engaged in self-harm behaviors (head banging, scratching, etc) when distressed

Onset

Failure to form normal social relationships (poor eye contact, not socially alert)

Onset

Unusual interests or play activities (preoccupied with spinning objects, patterns)

Onset

Unusual bodily movements (e.g. hand-flapping) or speech mannerisms

Onset

Childhood Health Issues (Does the child have a history of any of the following)

Frequent ear infections requiring prescription medication

Seizures

Head injury

Asthma

Trouble with hearing

Trouble with vision

Bedwetting after age 5

Bowel-control accidents (soiling) after age 4

Lead poisoning

Cancer

Major illnesses of hospitalizations

Prescribed medication to treat a medical problem

Child’s current primary care physician/clinic is

Would you like information to be shared with your primary care physician?

Functioning

Poor appetite

If yes, still occurring?

Constipation

If yes, still occurring?

Stomachaches

If yes, still occurring?

Trouble falling asleep

If yes, still occurring?

Trouble staying asleep

If yes, still occurring?

Over activity

If yes, still occurring?

Head banging

If yes, still occurring?

Tantrums

If yes, still occurring?

Shyness with strangers

If yes, still occurring?

Clingy

If yes, still occurring?

Self-injurious behavior (cutting on own skin, burning self on purpose, etc)

If yes, still occurring?

Suicidal statements

If yes, still occurring?

Serious threats to harm others

If yes, still occurring?

Physical aggression towards others

If yes, still occurring?

Cruelty towards animals

If yes, still occurring?

Sensory Issues

Poor muscle tone and/or coordination

If yes, still occurring?

Hypersensitive (overly sensitive) to touch

If yes, still occurring?

Hyposensitive (under sensitive) to touch

If yes, still occurring?

Hypersensitive (overly sensitive) to sounds

If yes, still occurring?

Hyposensitive (under sensitive) to sounds

If yes, still occurring?

Hypersensitive (overly sensitive) to visual input

If yes, still occurring?

Hyposensitive (under sensitive) to visual input

If yes, still occurring?

Hypersensitive to (overly sensitive) smells

If yes, still occurring?

Hyposensitive (under sensitive) to smells

If yes, still occurring?

Education/School Functioning

Performing below expectations at school

If yes, still occurring?

Learning problems

If yes, still occurring?

Repeated a grade (or is scheduled to repeat a grade)

If yes, still occurring?

Evaluated for special education services, but did not qualify for services

If yes, still occurring?

Receives special education services or has a 504 plan

If yes, still occurring?

Has an identified learning disability

If yes, still occurring?

Multiple detentions or suspensions

If yes, still occurring?

Truancy (with or without court action)

If yes, still occurring?

Receives special education services for behavior or emotional problems

If yes, still occurring?

Enrollment in an alternative learning center (ALC) or is home-schooled

If yes, still occurring?

Trauma History (Has the child experienced any of the following)

Physical abuse

If yes, still occurring?

Domestic violence/abuse

If yes, still occurring?

Physical neglect

If yes, still occurring?

Emotional abuse

If yes, still occurring?

Sexual abuse/molestation

If yes, still occurring?

Community violence

If yes, still occurring?

Children’s Protective Services involvement with the family

If yes, still occurring?

Other traumatic experiences or losses

If yes, still occurring?

Substance Use

Do you have any concerns about this child’s use of alcohol or drugs?

Alcohol

Tobacco

Caffeine

Marijuana

Methamphetamine

Narcotics

Cocaine

Heroin

Prescription Drugs

Other

Specify other substance

Other

To be completed by adolescents (ages 12-17)

Have you used more than one chemical at a time in order to get high?

Do you avoid family activities so you can use?

Do you have a group of friends who also use?

Do you use to improve your emotions, such as when you feel sad or depressed?

Legal issues as a result of use

Describe

Does this child have a history of participating in a chemical dependency treatment program?

If yes, please describe when and where they were in treatment

Legal History

Does this child have a history of legal charges?

If yes, please describe charges

Is the child currently on probation?

Has the child ever been on probation?

Oppositional and Defiant Behaviors

Are the following symptoms present?

Loses temper

Argues with adults

Actively defies or refuses to comply with adults’ requests or rules

Deliberately annoys people

Blames others for his or her mistakes or misbehavior

Is touchy or easily annoyed by others

Is angry or resentful

Is spiteful or vindictive, holds a grudge

Impulsive, Hyperactive and Inattentive Behaviors

Fails to give close attention to details, makes careless mistake in schoolwork

Has difficulty sustaining attention in tasks or play activities

Does not seem to listen when spoken to directly

Does not follow through on instructions and fails to finish work/chores

Has difficulty organizing tasks and activities

Avoids or dislikes to engage in tasks that require sustained mental effort (such as school work, homework)

Loses things necessary for tasks and activities (toys, assignments, pencils, etc)

Is easily distracted by extraneous stimuli

Is forgetful in daily activities

Fidgets with hands or feet or squirm in seat

Leaves seat in classroom, other situations

Runs about or climbs excessively in situations where it is inappropriate

Has difficulty playing quietly/leisure quietly

Is “on the go” or acts if “driven by a motor”

Talks excessively

Blurts out answers before questions have been completed

Has difficulty awaiting turn

Interrupts or intrudes on others

Mood Regulation

Rapid and extreme mood swings

Explosive rages

Periods of exaggerated sense of self-importance or achievement

Periods of having racing thoughts or fast speech

Periods of very elated mood, feeling excessively joyful

Periods of decreased need for sleep

Increase in goal-directed activity

Depressed mood

Irritability

Withdrawal

Indecisiveness

Crying spells

Excessive worry about many things

Specific fears

Nightmares

Exaggerated startle response

Anxiety Related Symptoms

Does your child have a distinct and ongoing fear of social situations involving unfamiliar people?

Does your child worry excessively about a number of events or activities?

Does your child experience shortness of breath or a racing heart for no apparent reason?

Does your child often appear anxious when interacting with peers, or try to avoid them?

Does your child have a persistent and unreasonable fear of an object or situation, such as flying, heights, or animals?

When encountering the feared object or situation, does he/she react by freezing, clinging, or having a tantrum?

Does your child worry excessively about her competence and quality of performance?

Does your child cry, have tantrums, or refuse to leave a family member or other familiar person when necessary?

Has your child experienced a decline in classroom performance, refused to go to school, or avoided age-appropriate social activities?

Does your child spend at least one hour each day repeating things over again, such as hand washing, checking, arranging, or counting?

Does your child have exaggerated and irrational fears of people, places, objects or situation’s that interfere with his or her social and academic life?

Does your child experience a great number of nightmares, headaches, or stomachaches?

Does your child repetitively use toys to re-enact scenes from a disturbing event?

Does your child redo tasks because of excessive dissatisfaction with less-than-perfect performance?

Strengths and Additional Information

Please identify some of this child’s strengths and interests

Please provide any additional information you would like to share

Patient Health Questionnaire (PHQ-9--Modified for Teens)

To be completed by adolescents (ages 12-18).

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Feeling down, depressed, irritable or hopeless

Little interest or pleasure in doing things

Trouble falling or staying asleep or sleeping too much

Poor appetite, weight loss, or overeating

Feeling tired or having little energy

Feeling bad about yourself --or feeling that you are a failure, or have let yourself or your family down

Trouble concentrating on things, like school work, reading or watching TV

Moving or speaking so slowly that other people could have noticed - Or the opposite – being so fidgety or restless that you were moving around a lot more than usual

Thoughts that you would be better off dead, or of hurting yourself in some way

In the past year

This question is cut off in the original PDF

If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Have you ever, in your whole life

This question is cut off in the original PDF

Download the PDF instead

Submissions are transmitted over an encrypted connection and stored securely for the TSA intake team. Typing your name in a signature field constitutes your electronic signature.