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Child and Adolescent Social History Questionnaire


Patient's Legal Name
First Name:
Last Name:

Family History:














List your brothers, sisters and yourself, from oldest to youngest (include ages):




Trauma History:

Have You Experienced?
Death of Significant other?Parents Separation?Parents Divorce?Sexual Abuse?Emotional Abuse?Bullying?Physical Abuse?Any Other Traumatic Event?

Educational History:







Occupational History:

Socio-Cultural History:







Legal History:




Substance Abuse History:





Sexual History: (For Adolescents)







Phone: 801.438.6059 | Fax: 801.501.0249

Draper Office

248 East 13800 South, #4
Draper, UT 84020
801.438.6059

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065
801.610.1573