Child and Adolescent Social History Questionnaire

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

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065