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Adolescent Questionnaire
Please answer the following questions accurately. Its okay to pass on some questions, but it really helps me to get
to know you and understand what might be bothering you, if you try to answer as completely and accurately as
possible.
Name: _________________________________________

Birthdate: ________________________

Age: _______ Grade in School:______________ School you attend: ____________________________


Are you working? ____________ If yes, what do you do? ____________________________________
Who do you live with? _________________________________________________________________
Siblings:
Name:_________________________________________ Age:__________________________
Name: ________________________________________ Age: __________________________
Name: _________________________________________Age: __________________________
Did someone raise you other than your biological parents? If so, who:
____________________________________________________________________________________
Have your parents ever been separated or divorced? __________________________________________
How would you describe the marriage of your parents with whom you live now or lived with most recently?
(happy, okay, unhappy, miserable) ________________________________________________________
How would you describe yourself?_________________________________________________________
____________________________________________________________________________________
What do you see as problems in your life? _________________________________________________
____________________________________________________________________________________
What have you been like to live with for the past six months? __________________________________
____________________________________________________________________________________
What was the most difficult thing you have experienced? When did it happen? _____________________
____________________________________________________________________________________
Symptoms/Issues: Please check all that apply and give an explanation if you can.
__ Communicating with parents __________________________________________________________________________
___Employment/School ________________________________________________________________________________
___Suicide thoughts, plans, attempts ______________________________________________________________________
___ Angry/violent behavior ______________________________________________________________________________
___ Mood Swings _____________________________________________________________________________________
____Drug/Alcohol _____________________________________________________________________________________
____ Legal issues _____________________________________________________________________________________
____ Sad, crying, depression ____________________________________________________________________________
____Change in weight, eating habits ______________________________________________________________________
____ Fatigue, tired all the time ___________________________________________________________________________

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____ Irritability, crabby behavior
_________________________________________________________________________
____ Sexual problems, worries ___________________________________________________________________________
____ Abuse (verbal, physical, sexual) ______________________________________________________________________
____ guilty, shameful feelings ___________________________________________________________________________
____ Hallucinations (seeing or hearing things that arent there)__________________________________________________
____ Spending habits __________________________________________________________________________________
____ Gambling/computer games _________________________________________________________________________
____ Shy, social problems ______________________________________________________________________________
____ Frequent lying ___________________________________________________________________________________
____ Physical problems, pain, illness _____________________________________________________________________
____ Feeling lonely ___________________________________________________________________________________
____ Other symptoms, worries, problems __________________________________________________________________

Alcohol and Drug History:


What types of alcohol and/or other drugs have you tried? _______________________________________
How old were you when you first tried them? _________________________________________________
How often do you currently use alcohol or drugs? _____________________________________________
Are you worried about your use? __________________________________________________________
Have you ever passed out while using drugs or alcohol or had to go to the hospital because of drug use? (when
and what happened?) ___________________________________________________________________
Treatment History:
Have you ever been taken to a mental health or chemical dependency professional before? If yes, please explain
who, where, and when ____________________________________________________________
Was the treatment or counseling helpful? Why or why not? _____________________________________
____________________________________________________________________________________
What do you want to get from counseling right now? __________________________________________
____________________________________________________________________________________
Emotional History:
What is your saddest memory? ___________________________________________________________
What is your happiest memory? __________________________________________________________
Do you talk about how your feeling or do you try to hide your feelings? ____________________________
Have you ever felt emotionally, physically, or sexually abused? (Please explain) ______________________
____________________________________________________________________________________
School Information:
What school do you attend? _____________________________________________________________
How do you feel about school? ____________________________________________________________
What are your grades like? _______________________________________________________________
Do you attend school and classes regularly? __________________________________________________

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Do you get along with your teachers? ______________________________________________________
What subject do you like least? ________________________________ Most? _____________________
Are you involved in after school sports/activities? If so what are they: _____________________________
___________________________________________________________________________________
Sexual History:
Do you have a boyfriend/girlfriend? ________________________________________________________
Are you sexually active? ________________________________________________________________
Do you use birth control? _______________________________________________________________
Have you ever had a sexually transmitted disease (STD)? ________________________________________
Have you ever been raped or had sexual contact you didnt want? (please explain) ____________________
____________________________________________________________________________________
Nutritional and Exercise History:
What is your weight? _______________________ What is your height?__________________________
How do you feel about your weight and height? _______________________________________________
What do you eat during the day? Breakfast, lunch, dinner, and snacks: _____________________________
____________________________________________________________________________________
____________________________________________________________________________________
Do you exercise or play sports? ___________________________________________________________
How much time do you spend watching TV or playing computer games? ____________________________
Social/Friendships:
How many close friends do you have? ______________________________________________________
Do you feel you can talk to your friends about your worries, problems? _____________________________
Do you ever get teased or bullied? (please explain) _____________________________________________
____________________________________________________________________________________
What do you like to do with your friends? ___________________________________________________
____________________________________________________________________________________
Do you feel you have enough friends and are you happy with your social activities? (please explain) _______
____________________________________________________________________________________
Spirituality/religion:
Do you attend church? _________________________________________________________________
Do you feel you are spiritual or religious? ___________________________________________________
Do you believe in a life after death? _______________________________________________________
Do you find comfort and support in a church community or in your spiritual beliefs? (please explain) ______
____________________________________________________________________________________
Please explain why you are seeking counseling/therapy? (ie. worries, problems with mood, parents made you
come, relationship problems, suicidal thoughts, other) __________________________________________
Thank you for completing this questionnaire!