Adolescent Psychosocial Asessment Page 7
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14Is there a history of suicide in your child’s immediate and/or extended family? Yes No
If Yes, please explain __________________________________________________________________________
___________________________________________________________________________________________
Has your child ever inflicted burns or wound on his/herself? Yes No
Is your child presently homicidal? Yes No If yes, please explain _______________________________
___________________________________________________________________________________________
Additional Information: (please list additional information as needed to address past and current safety issues)
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
CURRENT FUNCTIONING:
Do you have concerns about your child in the following areas? (check all that apply)?
Eating Hygiene/grooming Sleeping Activities/play Social Relationships
If so, please describe: __________________________________________________________________________
___________________________________________________________________________________________
Please rate your child’s personality/temperament (how they behave the majority of the time in each of the
following areas on a scale from 1 to 7 by placing a check above the number that best describes your child):
ENERGY/ACTIVITY LEVEL (how active is my child?)
CAN sit still and listen
CAN’T sit still and listen
for long periods of time ____: ____: ____: ____: ____: ____: ____ for long periods of time
1 2 3 4 5 6 7
NEED FOR PHYSICAL ROUTINE (how much routine does my child need)?
ENJOYS DOING THINGS
ENJOYS ROUTINE; easily
DIFFERENTLY; may not
upset when day doesn’t ____: ____: ____: ____: ____: ____: ____ notice small changes in
go as usual
1 2 3 4 5 6 7
the day
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