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DEVELOPMENTAL AND SOCIAL HISTORY FORM:
Name
First
Last
Date of Birth
MM slash DD slash YYYY
When you were born, were there any issues?
Yes
No
If yes, please explain:
Did you walk/talk at normal ages?
Yes
No
If no, please describe:
Did you ever experience trauma or abuse of physical, emotional, or sexual nature in your life?
*
Yes
No
Did you ever feel neglected by your parents or caregivers?
*
Yes
No
Do you have sibilings?
Yes
No
If yes, what are their names and ages?
Substance Abuse History
Substances
Alcohol
Marijuana
Opiates
Cocaine
Nicotine
Other
Alcohol: How Often?
Alcohol: How Much?
Alcohol: Last Use
Are you concerned about your use of alcohol?
Yes
No
Marijuana: How Often?
Marijuana: How Much?
Marijuana: Last Use?
Are you concerned about your use of marijuana?
Yes
No
Opiates: How often?
Opiates: How much?
Opiates: Last use?
Are you concerned about your use of opiates?
Yes
No
Cocaine: How often?
Cocaine: How much?
Cocaine: Last Use?
Are you concerned about your use of cocaine?
Yes
No
Nicotine: How Much?
Nicotine: How Often?
Nicotine: Last Use?
Are you concerned about your use of Nicotine?
Yes
No
Education History
What is the highest level of school you have attained?
Did you have to repeat any grades?
Yes
No
Did you have any problems in academic performance in school?
Yes
No
If yes, Please Explain:
Did you have any behavioral problems in school?
Yes
No
If yes, please explain:
Legal History
Have you ever been arrested?
Yes
No
If yes, please explain:
Any current or pending legal issues?
Yes
No
If yes: please explain:
Child Protective Services Involvement?
Yes
No
If yes, please explain:
Other History
Please list any allergies:
Height
Weight
Sexually active?
Yes
No
Birth Control?
Yes
No
N/A
If yes, type:
For women: still having menses?
Yes
No
Any other concerns you'd like to discuss?
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