Adolescent Psychosocial Asessment Page 12
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14To your knowledge, has your child ever overdosed or passed out on alcohol or other drugs?
Yes No If yes, when was the last overdose? __________________________________________
Has your child ever experienced problems related to their alcohol use?
Yes
No
If yes, please check area and describe problems:
Legal
Social/Peer
Work
Family
Friends
Financial
Please describe: __________________________________________________________________
If yes, have they continued to drink/use drugs?
Yes
No
LEGAL INVOLVEMENT:
Is there a current custody case involving your child?
Yes
No
If yes, please describe below.
History of CPS involvement:
None
Past
Current Please describe below.
Please indicate by checking your child’s legal status below.
No Involvement No Involvement Probation | Length: ____________
Parole | Length: ____________ Charges Pending Prior Incarceration
Law Suit or other Court Proceeding
Charges: _________________________ Probation/Parole Officer’s Name: ________________________
Contact #:____________________________________________________
Additional Information: ________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
HISTORY OF ABUSE/NEGLECT:
Has your child ever been abused or assaulted? Yes No If Yes, please complete the chart below.
Type of Abuse
By Whom? (relation to child if any)
At What Age?
Was it Reported?
Sexual
Yes No
Physical
Yes No
Emotional
Yes No
Verbal
Yes No
Abandoned/Neglected
Yes No
Has your child ever been a victim of bullying? Yes No
Do you worry about your child’s safety now? Yes No
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