• Child/Adolescent Biopsychosocial History

    Lisa Inoue LMSW PLLC
  • In preparation for our first appointment, please complete the information in the form below to the best of your ability. Feel free to leave any questions blank which are not relevant or which you would prefer not to answer, with the exception of the questions in the Concerns About Harming Self or Others section. Gathering a thorough history assists me in completing a comprehensive evaluation of your child/adolescent.

  • Identifying Information

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  • Presenting Concerns

  • Child's Strengths

  • Development

  • Medical

  • Concerns About Harming Self or Other

    This section is required
  • Education

  • Composition of Family and Household

  • Please complete the following for each significant caregiver. This may include biological parents, step-parents, adoptive parents, or guardians.

  • Family History

    Please consider grandparents, great-grandparents, aunts, uncles, siblings and cousins when answering this set of questions:
  • Family Style and Resources

  • Other

  • Clear
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  • Should be Empty: