Child and Adolescent Social History Questionnaire

Please fill out Online or Download and bring in

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

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065