If yes, when was your child tested? If yes, by whom? Comment on any strengths/concerns for child in educational setting LEGAL HISTORY CHILD’S Does your child have a history of legal charges? ☐ Yes ☐ No If yes, describe charges: ☐ ☐ Is your child currently on probation? Yes No Has your child ever been on probation? ☐ Yes ☐ No ☐ ☐ Has your child ever been court-ordered into chemical health or mental health treatment? Yes No TRAUMA HISTORY CHILD’S Has your child ever experienced Physical neglect: ☐ Yes ☐ No any of the following? Sexual abuse/molestation: ☐ Yes ☐ No Emotional abuse: ☐ ☐ Yes No Community violence: ☐ Yes ☐ No Car accident: ☐ ☐ Yes No Death of parent: ☐ Yes ☐ No Natural Disaster: ☐ Yes ☐ No Other, please describe: If yes to any, please describe: MENTAL HEALTH TREATMENT CHILD’S Previous and current mental health ☐ ☐ Yes No If yes, please list reason for treatment, provider name and dates of services: treatment? Currently on any medications? ☐ Yes ☐ No If yes, please list medication: Are you allergic to any medications? ☐ ☐ Yes No If yes, please list medication: ALCOHOL AND DRUG HISTORY CHILD’S Do you have any concerns about your ☐ ☐ Yes No If yes, please describe use of drugs or alcohol? child’s Smoking Status ☐ ☐ If Current Smoker: Some Every Day ☐ ☐ ☐ Former Smoker Never Unknown
If yes, when was your child tested? If yes, by whom? Comment on any strengths/concerns for child in educational setting CHILD’S LEGAL HISTORY Does your child have a history of legal charges? ☐ Yes ☐ No If yes, describe charges: Is your child currently on probation? ☐ Yes ☐ No Has your child ever been on probation? ☐ Yes ☐ No Has your child ever been court-ordered into chemical health or mental health treatment? ☐ Yes ☐ No CHILD’S TRAUMA HISTORY Has your child ever experienced any of the following? Physical neglect: ☐ Yes ☐ No Sexual abuse/molestation: ☐ Yes ☐ No Emotional abuse: ☐ Yes ☐ No Community violence: ☐ Yes ☐ No Car accident: ☐ Yes ☐ No Death of parent: ☐ Yes ☐ No Natural Disaster: ☐ Yes ☐ No Other, please describe: If yes to any, please describe: CHILD’S MENTAL HEALTH TREATMENT Previous and current mental health treatment? ☐ Yes ☐ No If yes, please list reason for treatment, provider name and dates of services: Currently on any medications? Are you allergic to any medications? ☐ Yes ☐ No If yes, please list medication: ☐ Yes ☐ No If yes, please list medication: CHILD’S ALCOHOL AND DRUG HISTORY Do you have any concerns about your child’s use of drugs or alcohol? ☐ Yes ☐ No If yes, please describe Smoking Status If Current Smoker: ☐ Some ☐ Every Day ☐ Former Smoker ☐ Never ☐ Unknown
History-Form-Child-Adolescent.docx