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Zumbro Valley Health Center
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  • Mental Health
    • Adult Counseling
      • ARMHS
      • Substance Use & Recovery Services
    • Community Support
    • Depression & Anxiety Treatment
    • Integrative Healthcare & Wellbeing
    • Medication Management
    • Mobile Crisis Stabilization
    • Residential Treatment Services
    • Support Groups
    • Telehealth
    • Veteran Services
    • Youth and Family Counseling
      • ADD/ADHD
      • Mood or Behavior Disorders
      • Trauma Treatment
      • Psychiatric Evaluation
      • School-Based Services
      • Substance Use & Recovery Services
  • Substance Use
    • Counseling
    • Detoxification
    • Drug Testing Services
    • DWI Education
    • Support Groups
  • Your Visit
    • What To Expect
    • About Us
    • Annual Report
    • Locations
    • Insurance Accepted
    • Client Forms
    • Make A Referral
  • Providers
    • Meet The Team
    • Leadership and Staff
    • Licensing and Certifications
  • Resources
    • Classes & Groups
    • Types of Therapy
    • Teachers & Parents
    • Educational Videos
    • FAQs
    • News
  • Toggle website search
  • Make a Referral

Child and Adolescent Personal History Questionnaire

  • MM slash DD slash YYYY
  • First NameLast NameEmail Address 
  • Referral Source

  • Assessment Overview

  • Please provide examples of behaviors that you are concerned about.
  • (select all that apply)
  • (select all that apply)
  • Chemical Use History

  • Medical History

  • Name of MedicationDosage (if known)Reason for use (if known) 
  • Mental Health History

  • Date of serviceWhere the client was seen/treatedFocus of treatment 
  • MedicationDosage (if known)Reason for use (if known) 
  • Social/Relationship History

  • NameAge 
  • (time with friends, hobbies, sports, etc.)
  • Education/Work History

  • (Please be specific and include how many schools the client has attended, academic progress, social involvement, extra-curricular involvement, getting along with teachers and peers, etc.)
  • (Please include in/out of school suspensions, expulsions, truancy, or other academic issues)
  • Please bring a copy of the plan to the client's appointment.
  • Legal History

  • Family History

  • NameRelationshipAgeOccupationAlive? (Yes/No) 
  • NameRelationshipAgeOccupationAlive? (Yes/No) 
  • NameRelationship 
  • At about what age did the client complete the following?

    (mark NA if not yet obtained)
  • Coordination of Care

  • This field is for validation purposes and should be left unchanged.

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Zumbro Valley Health Center

507.289.2089

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  • Monday - Thursday - 7:30am - 7:00pm
  • Friday - 7:30am - 12:00pm
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