Adolescent Psychosocial Asessment Page 11
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14FAMILY MENTAL HEALTH HISTORY
Please identify if any members of your family have had a history of any of the following mental health/drug
abuse/legal concerns.
Family History
Depression
Anxiety
Bipolar
Schizophrenia
ADHD/ADD
Trauma
Abusive
Alcohol
Drug
Incarceration
Disorder
History
Behavior
Abuse
Abuse
Self
Mother
Father
Sister
Brother
Maternal
Uncle
Paternal
Uncle
Maternal
Aunt
Paternal
Aunt
Maternal
Grandmother
Paternal
Grandmother
Maternal
Grandfather
Paternal
Grandfather
Biological
Child
Additional Information: ________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
ALCOHOL/DRUG ASSESSMENT:
Does your child use tobacco or smokeless tobacco? Yes No Do not know
Does your child use alcohol or drugs? Yes No Do not know
To your knowledge, has your child ever used medications (prescriptions drugs or over the counter medication)
recreationally? Yes No Do not know
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