Family History Form

FAMILY HISTORY FORM

THE FAMILY GUIDANCE AND THERAPY CENTER
Please complete and submit. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your family.
Family last name(s):*
Date:*

MonthDayYear
Date
Name of person filling out form:*
Family members first names:*
Family members dates of birth:*
Preferred contact phone #*
Primary insured individual's name*
Social Security #*
Primary insured individual's DOB*

MonthDayYear
Date
Address*
Email address*
example@example.com
Emergency contact name & phone number*
Family's ethnicities:
Family's preferred language:
Family's religion (if applicable)
Seeking the following services:*

Relationship Development Intervention (RDI)Family TherapyIndividual TherapyBehavioral TherapyParent TrainingGroup TherapyOther: Please specifyEducational Consultation
Primary reason(s) for seeking services:*

Autism SpectrumSocial IssuesDevelopment DelaysAnger ManagementParenting IssuesAnxietyCopingFear/PhobiasCompulsive BehaviorsDepressionSexual ConcernsAlcohol/DrugsEating DisordersSleeping ProblemsHyperactivity
Other mental health concerns (specify)*
Please answer the following questions to the best of your ability:
1. Goals: What are your goals for coming here? Please be as specific as possible.
2. Opinions: Is there any difference of opinion among different family members over whether problems exist, or what needs to be done? If SO, please give us each person's viewpoint of the problems and solutions.
3. Living Arrangements: Who currently lives in your home?*
4. Child Expectations: Does the child/children know why they are coming to their appointment? If so, what do they know and expect?*
5. Marriage: Please tell us about parents’ marital status. Is this the first marriage for both? If there were prior marriages, are there any children from them? Are parents divorced? Remarried? Separated? If divorced, tell us your opinion of the impact of the divorce on the child. Is there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling?*
6.Parent 1:*

Natural parentStep ParentAdoptive ParentFoster HomeOther
Please tell us about your occupation.
Is parent 1 currently working?*
Full time/part time?*
Where is parent 1 employed?*
Parent 1 work phone #*
Parent 1's education:*
Is there anything notable, unusual or stressful about the child’s relationship with parent 1?*

YesNo
If Yes, please explain:*
How is the child disciplined by parent 1?*
For what reasons is the child disciplined by the parent 1?*
7. Parent 2:*

Natural ParentStep ParentAdoptive ParentFoster HomeOther
Please tell us about your occupation.
Is parent 2 currently working?*
Part time/full time?*
Where is parent 2 employed?*
Parent 2 work phone:*
Parent 2's education:*
Is there anything notable, unusual or stressful about the child’s relationship with the parent 2?*

YesNo
If Yes, please explain*
How is the child disciplined by parent 2?*
For what reasons is the child disciplined by parent 2?*
8.Adoption: If your child was adopted, at what age was the adoption? What information do you have about the history of the biological parents and the child’s history before the adoption?*
9. Siblings: Tell us any important information about siblings that would help us.*
10. Family Health:

Have any of the following diseases occurred among your family’s blood relatives? (parents, siblings, aunts, uncles or grandparents) Check those which apply:
No health issuesAllergiesAnemiaPerceptual Motor DisorderBleeding TendencyBlindnessCancerCerebral PalsyCleft LipsCleft PalateMuscular DystrophyDiabetesGlandular ProblemsHeart ProblemsHigh Blood ProblemsKidney ProblemsMental IllnessMigrainesMultiple ScerosisDeafnessNervousnessAsthmaMental RetardationSeizuresSpinal BifidaSuicideOther
Comments re: family health
11.Stress: Please tell us about any recent stresses and crises that have occurred in the family in the last few years. For any stress you list, tell us how you think it may have affected your family. (Ie. parent who must work unusually long hours, divorce, moving, death) Also, include any anticipated future stresses.*
12. Medical History: Please share anything notable/significant about your family’s medical status, including neurological problems and allergies and note which family member was affected.*

No health issuesAbortionAsthmaBlackoutsBronchitisHivesCerebral PalsyChicken PoxCongenital ProblemsCroupDiabetesSexually Trasmitted DiseaseDizzinessEar AchesEar InfectionsHay feverEczemaHeart TroubleHepatitusHearingRheumatic FeverInfluenzaLead PoisoningMeaslesMeningitisMiscarriageMultiple SclerosisMumpsMuscular DystrophyNose BleedsOther Skin RashesPneumoniaPolioPregnancySpeechSendory/MotorScarlet FeverSeizuresSevere ColdsMeningitisHeadachesThyroid ProblemsVision ProblemsWearing GlassesWhooping CoughOtherEncephalitisParalysisFevers
List any current health concerns:*
List any recent health or physical changes:*
Do any of your family members take medications? If SO, please note who and what medication they are taking:*
13: Children's Education
Child 1 name:*
Current school*
Type of school:*

PublicPrivateHome SchooledOther
Grade*
Child 2 name:*
Current school*
Type a school:*

PublicPrivateHome SchooledOther
Grade*
Child 3 name:*
Current school:*
Type of school*

PublicPrivateHome SchooledOther
Grade:*
If your family includes more than 3 children please add their information in the box below.*
14. Parenting

Who handles responsibility for your child(ren) in the following areas?
School:*

Parent 1Parent 2SharedOther
Health:*

Parent 1Parent 2SharedOther
Problem behavior:*

Parent 1Parent 2SharedOther
15.Counseling/Prior Treatment History: Please share with us any prior about any prior counseling any member of the family has received. What worked? What did not work?*
16.Leisure/Strengths: Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc.) What are the family’s favorite activities? What does the child/adolescent do with unstructured time? What would you consider your child’s strengths to be? What do the parents enjoy doing?*
Any additional information that you believe would assist us in understanding your family?
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FAMILY HISTORY FORM