Medical and Psychiatric History Form – Adolescent Holistic Therapy

Please fill out the form as completely and accurately as possible. If any section does not apply, write “N/A” or “Not Applicable.” Return the form via email, mail, or in person prior to your child’s scheduled session.

Childs Information

First name

Last name

Date of Birth

Month

Day

Year

Age

Gender Identity

Male

Female

Non-Binary

Other

Address

Preferred Language Spoken at home

School Name and Current Grade Level:

___

Parent or Guardian Information

Name of Parent/Guardian Completing this Form

Relationship to the Child

Primary Phone

Secondary Phone (if applicable)

If address if different from the child's, please write it here:

Emergency Contact Information

Name of Emergency Contact:

Relationship to the Child

Primary Phone

Secondary Phone (if applicable)

Childs Medical History

Primary Care Physician’s Name and Contact Information:

List any current or chronic medical conditions or diagnoses:

Please include any past illnesses or surgeries, with approximate dates:

List any allergies (including medications, foods, or environmental):

Please provide current medications your child is taking, including dosage, frequency, and the reason they are prescribed:

Does your child take any daily supplements or vitamins? If so, please list:

Child's Mental Health History

Has your child ever been diagnosed with a mental health condition? If yes, please describe the condition and any relevant details:

Has your child ever received care from a mental health professional, such as a therapist, counselor, or psychiatrist? If yes, please include approximate dates and reasons for seeking help:

Please list any current or past psychotropic medications, including name, dosage, and reason prescribed:

Has your child ever been hospitalized for emotional or psychiatric reasons? If so, please include dates and reasons:

Is there a family history of mental health conditions or substance use issues? If so, please describe the relation to your child and the condition if known:

Behavioral and Emotional Observations

How would you describe your child’s general mood or temperament?

Have you noticed any recent or significant changes in your child’s behavior, appetite, sleep patterns, or energy levels?

Does your child appear to struggle with anxiety, sadness, anger, or mood swings? Please describe:

Has your child ever talked about or engaged in self-harming behavior, or expressed suicidal thoughts? If yes, please explain:

Educational & Social Information

What school does your child currently attend?

Has your child experienced any challenges at school, such as learning difficulties, behavioral issues, or frequent absences? If yes, please describe:

Does your child currently receive any special education services or academic accommodations (such as an IEP or 504 Plan)?

Has your child ever experienced bullying or difficulty fitting in with peers?

How does your child typically interact with siblings, friends, and other family members?

Substance Use

Are you aware of your child using any substances such as alcohol, tobacco, cannabis, or other drugs?

Yes

If yes, please describe the type of substance(s), how often it is used, and any additional information you feel is important:

Questions for Your Child (To be completed by your adolescent if possible)

How do you usually feel during the day—emotionally or physically?

What helps you feel calm, safe, or supported when you're having a hard time?

Do you enjoy school? Why or why not?

What activities or hobbies do you enjoy or feel passionate about?

Is there anything that has been hard for you lately or something you’d like support with?

What does healing or feeling better mean to you?

Is there anything you want me (your practitioner) to know about you?

Additional Notes from Parent or Guardian

Please share anything else you feel would be helpful for us to know about your child, their life, or their current challenges or strengths:

Consent

I, the undersigned, confirm that the information provided in this form is complete and accurate to the best of my knowledge. I understand this information will help support my child’s holistic care in a safe and informed manner.

Parent/Guardian Printed Name:

Parent/Guardian Signature

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Date

Month

Day

Year

Disclaimer: This form is intended for informational and therapeutic purposes only and does not serve as a substitute for a comprehensive evaluation or medical diagnosis by a licensed provider.

Medical and Psychiatric History Form – Adolescent Holistic Therapy

Childs Information

Parent or Guardian Information

Emergency Contact Information

Childs Medical History

Child's Mental Health History

Behavioral and Emotional Observations

Educational & Social Information

Substance Use

Questions for Your Child (To be completed by your adolescent if possible)

Additional Notes from Parent or Guardian