Adolescent Psychosocial Asessment Page 3
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14What else do you feel/believe would be helpful, or important for us to know/understand about your
relationships with your family or about your family members?
___________________________________________________________________________________________
___________________________________________________________________________________________
RECENT LOSSES:
Family Member Friend Health Lifestyle Job Income Housing None
Who? _______________________________ When? _________________ Nature of Loss? __________________
Other Losses: ________________________________________________________________________________
Additional information (if needed):
___________________________________________________________________________________________
___________________________________________________________________________________________
PREGNANCY & BIRTH HISTORY:
Were there any complications during pregnancy? Yes No If yes, please explain: __________________
___________________________________________________________________________________________
Full‐term Birth Premature Birth
Were there any complications during birth? Yes No If yes, please explain: ___________________
___________________________________________________________________________________________
Were drugs or alcohol consumed during pregnancy? Yes No
Child’s weight at birth? ______ lbs. ______ oz. Child’s health at birth? ________________________________
Length of hospital stay? ______________________________________ Post‐partum depression? Yes No
Was your child adopted? Yes No If yes, at what age? ____________
Domestic adoption International adoption (Country: _______________________)
DEVELOPMENTAL HISTORY:
As accurately as you can remember, how old was your child when she/he:
Rolled over? ______ Crawled? _______ Walked? ______ Talked (two words)? ______ Toilet Trained? _______
Do/did you have concerns about your child’s development in any of these areas (below)?
Speech/Language Motor Skills Cognitive/Intellectual Sensory Behavioral Emotional Social
If so, please describe: __________________________________________________________________________
___________________________________________________________________________________________
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