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Child and Adolescent History Form

Child and Adolescent History Form

Please bring this completed form with you to your first appointment                                                                                                                                                             _

Referral Information:

Child's name _________________________________________ Date Completed: _____________________ _

Child's Birth Date: ____________________________ Age            Sex:     _

Home Address: ________________________________________________________________________ _

Home Phone Number: __________________________________________________________________ _

Child's Cell Phone Number: _______________________ _

Parent's Name _______________________________ Work Number: ____________________________ _

                                                                               Cell Number: ______________________________ _

Parent's Name: ______________________________ Work Number: ____________________________ _

                                                                              Cell Number: _______________________________ _

                                                                                                                                                        By whom were you referred? ______________________________________________________________________________ _

                                                                                                                                                        Person completing this form: _________________________________________________________________________________ _

                                                                                                                                                     Describe your concerns about your child: ______________________________________________________________________ _

 

 

Give a brief history of these concerns (length of time you have been concerned, a description of any
factors you think may be contributing to the difficulty, previous attempts to resolve these issues):

 

 

What goals do you have for your child's assessment and/or treatment?

 

Briefly describe your child's strengths:

 

What does your child enjoy doing the most?

 

What extra-curricular activities or hobbies does your child participate in?

 

List any major stresses or changes that have occurred to your child or family in the past several years:

 

Indicate past and current counseling or evaluation services your child has received:

Counselor

Dates Seen

Records Available


 SCHOOL INFORMATION

Child's School ________________________________________________ Grade ____________________ _

Address of School _______________________________________________________________________ _

School Phone Number __________________________________________________________________ _

Describe your child's academic strengths: _________________________________________________ --:--

Describe areas of academic concern for your child: _________________________________________ _

How would you rate your child's overall intelligence level compared to other children?

__ below average __ average                __ above average         __ gifted

To the best of your knowledge, at what grade level is your child functioning?

Reading __          Spelling __          Writing __             Math

School Achievement/Ability resting results (if known): __________________________________________ _

List other schools your child has previously attended:

School _____________________________________________________ Years _____________________ _

School                                                            Years _____________________ _

School                                                             Years _____________________ _

  At what age did you child enter Kindergarten?             _

  Has your child ever repeated a grade?              _

   Present grade placement: regular class or special class _

  If in a special class, please specify Intensity Level (I-VI) and educational diagnosis:             _

Does your child currently receive any remedial services at school or other facilities: ________________ _

Specify: _______________________________________________________________________________ _

Describe any concerns raised by your child's current or past teachers: ___________________________ _


Background Information

Is your child adopted? ____ _

If yes, at what age? ___________ _

Pregnancy

How long was the pregnancy? ______________________ Birth Weight: _____________________ _

Delivery

Indicate any complications during delivery: _______________________________________________ _

Indicate any problems or special treatment required for your infant at the time of birth:

Developmental History

Infant/Toddler

Describe your child's temperament as an infant/toddler, (e.g. easy, cuddly, underactive, overactive,

colicky, difficult to soothe, etc): ________________________________________________________ _

Indicate the age at which your child reached the following developmental milestones. If you cannot
recall exactly, indicate early, normal or late relative to typical development:

Walked

Spoke first words

Said phrases

Toilet trained (day)

Toilet trained (night)

Dressed self

Tied shoes

Indicate with a checkmark any difficulties your child exhibited as an infant/toddler that seemed
excessive when compared to other children:

___restlessness

__ frequent head banging

__ constantly into everything

__ excessive accidents

__ poor speech articulation

__ delayed language development

 __ floppy or stiff

__ poor coordination

__ poor weight gain

__ poor eye contact

__ feeding problems

__ other (specify) ______________________________ _


Please describe any major life stresses that occurred to your child or family during your child's infancy or early childhood:       _

                                                                                                                                                     Briefly describe the style of parenting used in the household by both parents: ________________________________________ _

                                                                                                                                                     Describe how your child is disciplined: ________________________________________________________________________ _

                                                                                                                                                     For what reasons is the child disciplined? _____________________________________________________________________ _

List your child's main difficulties at home:

1.
2.
3.

Briefly describe your child's friendships:


Primary Care Physician:


 Child's Medical History and Status

Name: ______________________________________________________ _

Address: ___________________________________________________ _

 Phone: _____________________________________________________

please list any medical diagnoses or concerns: 

__________________________________________________________________________________________________________________________________________

 

 ________________________________________________________________________________________________________________________________                                              _

 __________________________________________________________________________________________________  Present or chronic illnesses for which the child is being treated:             _

Medications that the child is currently taking (indicate dosage and prescribing physician):

Please indicate with a checkmark if you child's medical history includes any of the following:

 __ complications of childhood diseases    seizures

  __ cuts and stitches (how many times? __ )    comas         __ broken bones (how many times? __ )  

  __ eye problems  serious illnesses      ear infections

__ hospitalizations
__ mild or major head injuries
__ poisoning
__ persistent high fevers
__ allergies

__ other (specify) _________________________ _

Please provide details concerning checked items: _____________________________________________ _

Is there any history of sexual or physical abuse? ~ If yes, please specify: ________________________ _


Behavioral Information

All children exhibit, to some degree, some of the behaviors listed below. Check those that you believe
your child exhibits to an excessive or exaggerated degree when compare to other children.

Feelings

 __ moody
sad

__ lack of enjoyment

underactive
__ low energy

__ dislikes self/low self-esteem
feels unloved

death ideas

__ past/present suicidal ideas
overexcitement
Learning Issues

__ has difficulty grasping concepts

doesn't seem to understand directions
__ poor memory

__ does not seem to work to potential
__ perfectionist

doesn't seem motivated
__ difficulty expressing self

__ difficulty with small motor skills
__ difficulty with gross motor skills

Behavioral Issues

__ losses temper

__ argues

__ non-compliant or disobedient
__ annoys others

blames others for mistakes
__ easily annoyed

__ angry

__ spiteful

__ bullies, threatens, or hurts others
__ cruelty to animals

__ stealing

__ fire-setting/match play
__ lying

__ truancy

__ running away

__ violates parental rules

Communication

hard to understand child

__ has difficulty understanding others
__ stuttering

__ fails to speak in some settings


 Activity and Attention 

careless mistakes
__ poor attention span

does not seem to listen
__ does not complete tasks
__ disorganized

__ loses things

__ easily distracted

__ forgetful

__ overactive, fidgety
__ can't stay in seat

__ acts as if "driven by a motor"
__ overly talkative

__ interrupts

__ difficulty waiting turn

Worries

fearful

__ excessively shy

__ afraid to leave parent

afraid in new situations
__ frequent worrying
__ panicky

__ repetitive behavior
__ thumb-sucking
__ nail-biting

irritable

needs much reassurance
Social Issues

has few or no friends
__ teased by others

avoids other children
__ rejected by others
__ acts younger than age
__ acts older than age
__ difficulty sharing

unusual or "odd"child
__ bossy

withdrawn

__ poor bond with parent (s)
Other

__ eating problems
__ sleeping problems
__ wetting problems
__ fecal soiling

__ jealous of siblings

__ tics or "funny" movements

Please specify other concerns: __________________________________________________________ _


Family History

Household

People with whom the child lives (specify parent, step-parent, sibling, half-sibling, step-sibling,
Grandparent, etc.)

NAME AGE RELATIONSHIP TO CHILD 

1.. 

2.
3.
4.
5.
6.


 How long have you lived at the current address? ________________________________________ _

Language spoken athome: ___________________________________________________________ _

If parents are separated or divorced, child's age at time of separation/divorce: ________________ _

Who has legal custody of child? _____________________ Describe living/visitation arrangements for

child:

-----------------------------------

Mother's History

Mother's full name: ________________________________________________ Age: _____________ _

                                                                                                                                                    Occupation:   _

Place of Employment: ________________________________________________ Number of years:       _

 School: Highest grade completed:            _

 Degree Completed: ____________________________________ _

 Learning or behavioral problems: _______________________ _

                                                                                                                                                 Medical Problems:

       _

  Specify mental health concerns (past and present): ________________________________________ _                                             _

Reproductive History:

Number of pregnancies: ______________________ _

Number of live births: _________________________ _

Number of miscarriages: ______________________ _

Number of therapeutic abortions: ______________ _

Father's History

Father's full name: ________________________________________________ Age: ______________ _

Occupation: __________________________________________________________________________ _

Place of Employment: ___________________________________________________ Number of years:      _

School: Highest grade completed:                                                          _

            Degree Achieved:                                                                      _

            Learning or behavioral problems: _________________________ _

Medical Problems: ___________________________________________________________________ _

Specify mental health concerns (past and present): ________________________________________ _

 

Extended Family History

Please indicate with a checkmark whether there is any family history of any of the following difficulties.
Include parents, sibling, grandparents, aunts, uncles, cousins. If present, please specify relationship.

Difficulty                                                                               Relationship

 

___ Mental Retardation

___ Attention Deficit Disorder or Attention Problems

___ Tourette's Syndrome or Tic Disorder

___ Learning Problems/Failure

___ Communication Disorder

___ Autism

___ Anxiety Problems

___ Obsessive Compulsive/Repetitive Behaviors

___ Depression

___ Suicide Attempt

___ Sexual or Physical Abuse

___ Drug Abuse

___ Alcoholism

___ Legal Difficulties

___ Schizophrenia

___ Psychiatric Hospitalizations

___ Use of Psychiatric Medication

___ Thyroid Problems

___ Genetic/Metabolic Disorders

___ Other Mental Health Concern

 Additional Comments:

Please use the space below to describe any other information you feel would be helpful to us in
understanding your child and your concerns.