Adolescent Psychosocial Asessment Page 6
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14PSYCHIATRIC/PSYCHOLOGICAL HISTORY:
Is your child currently being seen by a counselor? Yes No
If yes, name of current counselor ___________________________ Length of Treatment _____________
Is your child currently being seen by a psychiatrist? Yes No
If yes, name of current psychiatrist __________________________ Length of Treatment _____________
Has your child ever been diagnosed with a mental health, emotional or psychological condition?
Yes No
If yes, what diagnosis was your child given? ________________________________________________
When? _______________________________________________________________________________
By Whom? ___________________________________________________________________________
Has your child received counseling services or been hospitalized for mental health or drug and alcohol
concerns in the past? Yes No
If yes, please list previous counseling/hospitalizations for mental health/drug and alcohol concerns below
Dates of Service
Place/Provider
Reason for treatment
Were the services helpful
Additional information: _______________________________________________________________________
___________________________________________________________________________________________
SAFETY CONCERNS:
Is your child presently suicidal? Yes No If Yes, please explain ___________________________________
Has your child ever attempted to commit suicide? Yes No If yes, when and how? ________________
___________________________________________________________________________________________
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