Client History – Family Client History – Family Members Client User Code (Do not include names) * Your Email * Relationship With Client * How long have you known the client (in years) * Presenting Complaint * (In this section, please include information on why the client is seeking therapy). History of Presenting Complaint * (In this section, please include information on the history of presenting complaints i.e. series of notable events that led to the presenting complaints) Has there been any notable events that happened in the clients life over the last 3 years? Client’s Relationship with Parents * (In this section, please include information on the client’s relationship with a parent, both parents) Client’s Relationship with Siblings * (In this section, please include information on the client’s relationship with siblings) Client’s Relationship With Friends * (In this section, please include information on the client’s relationship with friends. Also, include information on the quality and quantity of client’s friends) Pre-morbid Personality * (In this section, please include information on the personality of the client before presenting complaints. E.g. Was the client jovial, impulsive, etc.?Please indicate if there has been any change in personality since after presenting complaints) Patients Drug and Alcohol History * (In this section, please include information on the client’s drug and alcohol history, if any) Trauma History (In this section, please include information on any form of childhood/adolescents trauma such as accidents, sexual abuse, physical abuse, emotional abuse, forced separation from a loved one or environment, bullying, etc.) Academic History * (In this section, describe client’s academic performance and involvement) What has been the family’s response since after presenting complaints (e.g. angry, supportive, non-involved, etc. Please provide details and context) * Any Additional Information, if none, write None If you are human, leave this field blank. Submit Δ
