Adolescent HEADSS Assessment form

Home
Who lives with you at home? List number of adults in house and relationship to
you__________________________________________________________________________________
___________________________________________________________
Do they have their own room? ___________
What are relationships like at home? ___________________________________________________
What do parents and relatives do for a
living?________________________________________________________________________________
__________________________________
Have you ever been institutionalized or Incarcerated? _______________ Reason for institutionalization
or incaceration_____________________________________________________________________
Any Recent moves or running away from home?_______________________
Any new person in home environment?____________________
Education and employment
What grade are you in at School and what is your grade performance?
_____________________________________________________________________________________
_____________________________________________________________________________________
Any past or recent changes in grades or school performance? _______________,If yes, explain what you
think is responsible for the
change_______________________________________________________________________________
_____________________________________________
Favorite subjects and worst subjects? (include grades)
_____________________________________________________________________________________
__________________________________
Any years repeated or classes failed? _____________________________________________________
Any Suspensions, termination or dropping out of school? __________________________________
What are your future education/employment plans?
_____________________________________________________________________________________
_________________________
Any current or past employment?_______________________________________________

Relations with teachers, employers--school, work attendance? _________________________________

Activities
What do you do for fun?, where?
when?_______________________________________________________________________________
_______________________________
Do you exercise regularly?___________________
How much TV do you watch? ________________________
If you drive a car, do you have a license? __________________
If you drive a car, do you always use a seat belt?_______________________
If you drive a car, have you ever been given a speeding ticket or a DUI ticket?____________
Drugs
Do you use tobacco or alcohol?_____________________________________
Does any family member use tobacco, alcohol or other illicit drugs?________________________
If you use tobacco or alcohol, how much and how frequently do you use
each?________________________________________________________________________________
__________________________________
How do you obtain alcohol or tobacco? (include source of funds and/or how they are paid
for)__________________________________________________________________________________
_____________________________________________________________________________________
___________________________
Sexuality
What is your sexual orientation? ________________________________________________________
Have you ever had sex_________________________________________________________________
Age of first sexual intercourse__________________________________________________________
Number of partners? _________________________________________________________________
Do you Masturbate? __________________________________________________________________
Have your ever been pregnant or had an abortion?___________________________________________
Have you ever had a Sexually transmitted diseases?
_____________________________________________________________________________________

_____________________________________________________________________________________
_____________________________________________________________________________________
_
Do you use contraception? What type? Frequency of use?
_____________________________________________________________________________________
____________________________________________
Have you ever experienced sexual or physical abuse? _________________________
Suicide/Depression
Do you have any problems sleeping? If yes,
describe______________________________________________________________________________
___________________________________________________
Are you
depressed?____________________________________________________________________________
____________________________________
Do you think about
suicide_______________________________________________________________________________
_________ if yes, do you have a plan_________________, Describe
plan_________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________
Have you ever attempted
suicide_______________________________________________________________________________
__________________________________________________________