Child and Adolescent Social History Questionnaire Date (required) Patient's Legal Name (required) Patient's Preferred Name Email of Parent or Guardian (required) Family History Date Of Birth (required) Place Of Birth Primary city (or cities) of residence during childhood and adolescence Natural Father's Name: Is he living? YesNo His Place of Employment Please describe your father. Please describe your relationship with your father. Natural Mothers's Name Is she living? YesNo Her Place of Employment Please describe your mother. Please describe your relationship with your mother. Please list everybody that lives with you Step-father's Name Place of Employment Description of Step-Father. Step-Mothers's Name Place of Employment Description of Step-Mother. 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? If you answered yes to one of the above, please explain the circumstances and your age when these events occurred. How is discipline handled in your home? Educational History Present grade in school: Where do you attend school: What are your normal grades in school: have you ever been suspended from school: YesNo If yes, please explain: Have you ever been truant from school: YesNo If yes, please explain: Occupational History Please list all jobs you have held, if any, including your present place of employment Socio-Cultural History How would you rate the financial status of your home? Do you have a strong support group of friends? YesNo Please describe any significant problems with your friends: What role does religion play in your family? What is your religious preference? Are you active in your religion? YesNo To which racial or ethnic group do you primarily identify? Legal History Have you experienced any legal problems? YesNo If yes, please describe Are you currently involved with any legal issue? YesNo If yes, please describe Substance Abuse History Have any of your family members had problems with alcohol and/or drug abuse? YesNo Please describe who, their relationship to you, and the substances they abused Please describe your alcohol and/or drug use, past and present. Have you ever received treatment for substance abuse? YesNo If so, when and where? Sexual History (For Adolescents) Have you ever engaged in sexual intercourse? YesNo If yes, at what age did you first engage in sexual intercourse? How Satisfied are you with the quality of your currnet sexual activity? How do you identify your sexual orientation? How do you identify yourself in terms of gender identity? What are your preferred pronouns? Do you have any concerns related to your gender identity of your sexual orientation? If so, please describe.