|
SOCIAL HISTORY
|
|
|
Who is your Support System?:
|
|
|
In what social/recreational activities does the client engage in?
|
|
|
Are there any social/recreational activities or hobbies the client enjoys with friends/family?
|
|
|
EDUCATIONAL/VOCATIONAL HISTORY
|
|
|
Highest grade client completed?
• • •
|
Last School Attended
|
|
Are you currently in school?
|
Learning Disability daignosed
|
|
In school did/do you have a 504?
|
In school did/do you have an IEP
|
|
Special Education /Learning Disability Comments
|
|
|
College Training
|
College Training Where
|
|
Vocational Schooling
|
Vocational Schooling Where
|
|
Special Training
|
Special Training Where
|
|
Vocational History
• • •
|
Current Employment
|
|
Current Employment Explain
|
|
|
Past Employment
|
Past Employment Duration
|
|
Past Employment Explain
|
Reason for Leaving
|
|
Describe the client’s employment strengths and resources/ Functioning academically at school?
|
|
|
Describe the client’s behaviors at school or work and abilities/difficulties in getting along with others:
|
|
|
Has the client:
• • •
|
If yes, Describe:
|
|
MILITARY SERVICE
|
|
|
Military Service
|
Military Service Branch
|
|
Military Service Active Duty
|
Military - Type of Discharge
|
|
LEGAL HISTORY (Explain if Necess
|
|
|
Current Legal Problems
• • •
|
|
|
Has Client ever been detained or arrested?
|
|
|
If yes, explain:
|
|
|
Has Client ever Gone to court or appeared before a judge for a legal infraction?
|
|
|
If yes, explain:
|
|
|
Has Client ever been on parole/probation or under court supervision?
|
|
|
If yes, explain:
|
|
|
Has client ever been remanded to dentition center or county/state training school?
|
|
|
If yes, explain:
|
|
|
CLIENT'S DEVELOPMENTAL HISTORY
|
|
|
Development
• • •
|
Development Explain
|
|
TRAUMA & ABUSE HISTORY
|
|
|
Physical
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
Describe - Duration
|
|
Emotional
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
Describe - Duration
|
|
Sexual
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
Describe - Duration
|
|
Neglect
• • •
|
Describe- Nature of Relationship
|
|
Describe - Severity of Abuse
|
Describe - Duration
|
|
Has the client ever feared that she/he will be injured or killed?
|
|
|
Has the client ever feared that a family member or anyone else will be injured or killed?
|
|
|
Seen someone injured or die
|
Die or Injured Comments
|
|
Sexual History
|
|
|
Has client reached puberty?
|
|
|
Client First Sexual Encounter Ag
|
Was this consensual
|
|
Is client sexually active
|
Any safety issue?
|
|
Has client engaged in any inappropriate sexual behavior?
|
|
|
If YES, explain:
|
|
|
Substance Abuse History
|
|
|
Does client have a current/ past history of substance abuse?
|
|
|
If yes describe:
• • •
|
|
|
description:
|
|
|
Has the client had any alcohol or substance abuse treatment to include:
• • •
|
|
|
Have there been any legal/other consequences of the client’s substance abuse?
|
|
|
If yes, explain:
|
|
|
If yes, explain:
|
|
|
Does the clients family have a current/past history of alcohol or substance abuse?
|
|
|
If yes, describe identifying family member(s), roles(s) and details including treatment outcomes:
|
|
|
Have there been any legal/other consequences of family member’s substance abuse?
|
|
|
If yes, describe:
|
|
