Date: ____________

TEEN QUESTIONNAIRE
Instructions: To assist in helping you, please fill out this form as fully and openly as possible. All of the information
on this form is held in the strictest confidence within legal limits. If certain questions do not apply, please leave
them blank.

Name:___________________________________ Preferred name: ________ Date of Birth: ________Gender: M/F

What grade are you in? __________ Name of School: __________________________________________________
Do you work?
Yes
No If yes, where? _____________________________________________________
How many hours/week on average do you work? _____________________________________________________

Presenting Concern(s):
What issues or problems bring you to therapy? _______________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

How long have these issues/problems occurred? _____________________________________________________

To what extent do these issues/problems impact your daily life or functioning?

not at all
very little
some
quite a bit
severely

What do you hope will change as a result of this therapy? ______________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________

Medical History/Information:
Do you have any concerns about your physical health? If yes, please specify: _______________________________
_____________________________________________________________________________________________

Please list any psychotherapy or chemical dependency treatment you have received in the past: ______________
_____________________________________________________________________________________________

How would you describe the result of that psychotherapy? What was helpful about it? ______________________
_____________________________________________________________________________________________

Family Information:
Your Father’s Name: __________________________Occupation:________________________________________

What is your relationship with your father like? _______________________________________________________

_____________________________________________________________________________________________

Is there anything you would like to change about your relationship with your father? If yes, please specify: _______
_____________________________________________________________________________________________

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Mother’s name: __________________________Occupation:________________________________________

What is your relationship with your mother like? _____________________________________________________

_____________________________________________________________________________________________

Is there anything you would like to change about your relationship with your mother? If yes, please specify: _____
_____________________________________________________________________________________________

Do you have concerns about either the drug or alcohol use of your parents? If yes, please specify: _____________
_____________________________________________________________________________________________

Do you think your parents are:
too strict
Not strict enough
just about right
Your parents’ relationship status:
Married
Separated
Divorced
Remarried

If applicable
Step-parent(s) name(s): __________________________________________________________________________

How would you describe your relationship with your step-parent(s)?

Step-mom: ____________________________________________________________________________________
Step-dad: _____________________________________________________________________________________

If your parents are divorced, please describe the details of the custody/visitation schedule (i.e. when you are with
each parent): __________________________________________________________________________________
_____________________________________________________________________________________________

If you could, is there anything you would change about this schedule? ____________________________________
_____________________________________________________________________________________________

Brothers and sisters: (indicate if step-brother or step-sister)

Name Age Sex Grade in Living at home?
school/occupation

Of your siblings, who are you closest to: _____________________________________________________________

Who do you fight with the most? __________________________________________________________________

Have any of the following stressful events occurred in the life of your family? If so, please indicate which ones, to
whom it may have occurred and how old you were when it/they occurred.

Death
Major illness
Sexual abuse
Physical abuse
Verbal abuse

Divorce
Change in residence
Foster placement
Hospitalization
Other
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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Personal Information:
List any extracurricular (in and out of school) activities in which you are involved: ___________________________
_____________________________________________________________________________________________

What do you like/dislike about school? _____________________________________________________________

_____________________________________________________________________________________________
_____________________________________________________________________________________________

List a few things you like about yourself and/or what others would say they like about you: ___________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

List a few things about yourself or your life you don’t like or would like to change? __________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

Please list any additional hobbies and interests: _____________________________________________________

_____________________________________________________________________________________________

Any concerns about your relationships with friends? If yes, please describe: ________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

What are your biggest fears? _____________________________________________________________________

_____________________________________________________________________________________________

Symptom Check-List:
Listed below are a number of common symptoms. Please check ALL that apply to you
(rate the severity for each one you’ve checked on a scale from 1-5; 1 = least severe 5 = most severe):

Frequent headaches
Often tired/exhausted
Weight loss/gain

Nausea/stomach trouble
Problems sleeping
Withdrawn

Unhappy/sad
Lonely/empty
Sudden changes in mood

Fearful/worried
Bored/uninterested in most things
Hopelessness

Feeling worthless
Numb-don’t feel much of anything
Nightmares

Feelings of panic
Crabby/irritable
Frustrated

Unable to concentrate
Can’t make decisions
Self-critical

Suicidal thoughts
Poor grades
Thoughts of hurting others

Worries about my health
Defy/break rules
Dishonest/lying

Angry outbursts/often angry
Physical fights
Try too hard to please others

No friends
Feelings of guilt/shame
Argue with parents

Keep secrets
Skip school

Engage in sexual behavior you don’t like
Sexual orientation issues

Repeats certain acts again and again
Self-injury (cutting, picking, burning)

Other-please specify:__________________________________________________________________________

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Nutrition:
Nutrition is very important to a person’s physical health and mental well-being. This is a simple screen to help us
determine any nutritional risks you may have.

Do you:
1. Eat breakfast most mornings?
Yes
No
2. Eat lunch at school?
Yes
No
3. Does your family eat meals together most days?
Yes
No
4. Exercise daily?
Yes
No
5. Eat a balanced diet including a variety of food and adequate amounts
(such as 3-5 servings of fruits & vegetables per day and 2-3 servings of milk)
Yes
No
6. Lost or gained over 10 pounds in the last 6 months without trying?
Yes
No
7. Suspect that you may have an eating disorder?
Yes
No
8. Spend more than 4 hours with the TV or computer each day?
Yes
No
9. Have any special dietary needs? (i.e. pregnancy, diabetes, allergies, etc.)
Yes
No
10. Take herbal supplements or other over-the-counter medications?
Yes
No

Please list any other concerns about your diet that we should know about: ________________________________
_____________________________________________________________________________________________

Chemical Use History:

1. Have you ever used alcohol or drugs?
Yes
No If YES, complete the questions below:

a. Used more than one chemical at the same time in order to get high?
Yes
No
b. Avoid family activities so you can use?
Yes
No
c. Have a group of friends who use?
Yes
No
d. Use to improve emotions such as when you may feel sad or depressed?
Yes
No

2. Do you smoke cigarettes?
Yes
No If YES, how many and how often:______________________
___________________________________________________________________________________

3. Do you consume caffeinated beverages?
Yes
No If YES, what beverage, how much and how
often?________________________________________________________________________________

Your Additional Comments:

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