NAME (Nicknames)

DATE OF BIRTH/ AGE

PLACE OF BIRTH

GENDER/CULTURAL BACKGROUND

WEIGHT/ HEIGHT
(Physical Description)

PURPOSE OF PSYCHOSOCIAL
(Chief Complaint)

REFERRAL
(Agency, Purpose)

SOURCES OF INFORMATION
(Informants, Documents)

PRESENT FAMILY CONFIGURATION

Parents
(Biological, Step, Foster, Adoptive)

Siblings
(Birth Order, Miscarriages)

Mother’s Family of Origin Configuration
(Parents, Siblings)

Father’s Family of Origin Configuration
(Parents, Siblings)

PRESENT ADDRESS
(Living Conditions)

CULTURAL BACKGROUND INFORMATION
(Historical/Geographical)

FAMILY HISTORY
(Biological and/or Present)

Marital Status
(Marriages, Divorces, Separations)

Parents Childhood
(Perception)

Re-locations

Economic Status
(Present, Generational)

Educational Level

Employment
(Career, Jobs, Volunteer)

Religion
(Affiliations, Practices)

Social Associations
(Membership, Alliances)

Recreational/ Leisure Activities
(Sports, Hobbies)

Medical
(Genetics, Illness, Injuries)

Mental Health
(Diagnosis, Hospitalizations, Outpatient)

Substance Use
(Alcohol, Prescriptions, Illegal Drugs)

Sexuality
(Preferences, Pornography)

Criminality
(Arrest, Ajudications, Sentences)

Deaths
(View)

Significant Events

EVENTS AT BIRTH
(Global,Local, Family)

PRENATAL CARE
(Medical, Emotional)

BIRTH
(Delivery, Medications)

INFANCY
(Perceptions)

DEVELOPMENTAL MILESTONES
(Speech, Gross Motor, Fine Motor, Toilet)

AGES 1-5
(Physical and Social Development/ Difficulties)

AGES 5-10
Traumatic Events Experienced/ Witnessed

AGES 10-15
Abuse (Physical, Sexual, Emotional)

AGES 15-20
Discipline
Habits
Fears (Bedwetting, Superstitions)
Impulse Control/ Frustration Tolerance
Eating and Sleeping Habits
Suicidal Behavior

HEALTH

Medical
(Genetics, Injuries, Illness)

Mental
(Diagnosis, Hospitalizations, Outpatient)

EDUCATION
(Child Care, Preschool, Elementary, Middle School, High School)

INVOLVEMENT IN CHILD PROTECTION SYSTEM
(Investigations, Protective Supervision, Foster Care, Adoptions)

SUBSTANCE USE
(Alcohol, Prescription, Illegal Drugs)

DELINQUENCY
(Arrest, Ajudications, Dispositions)

SEXUALITY
(Preference, Exposure, Dating)

PRESENT OBSERVATION
(Appearance, Mental Status)

CLINICAL IMPRESSIONS

PRESENT DIAGNOSIS

RECOMMENDATIONS