CHILDREN / ADOLESCENETS (A ge 17 and under) …

1 1 CHILDREN / ADOLESCENETS (Age 17 and under ) social / medical HISTORYBIOPSYCHOSOCIAL ASSESSMENTP leaseanswer all questions, do not write in boxes labeled psychologist use only. Thank sName: _____Date: _____Child s age: _____ Date of Birth: ____ / ____ / _____ Sex (circle one): Male FemaleAddress: _____ Street_____CityStateZipPhone: (Home)_____ (Cell) _____Person filling out form: _____Name of person responsible for bill: _____Emergency Contact: _____ Relationship _____ Phone _____Parents / StepparentsMother s name: _____ Age: _____ Education: _____ Occupation:_____Father s name: _____Age: _____Education: _____Occupation:_____Stepparent s name: _____Age: _____Education: _____Occupation: _____Stepparent s name: _____ Age: _____ Education: _____ Occupation: _____Marital status of parents: _____ If parents are separated/divorced, how old waschildat time ofseparation?

2 _____With whom does the child live? _____Custody: Lives in one home with both legal parents. Mother hasphysical custody. Father hasphysical custody. Physical custody is shared. Other: _____List all people living in household:NameAgeRelationship to child_____2If any brothers or sisters are living outside the home, list their names and ages:_____If any brothers / sisters are deceased, please give name and year: _____FAMILY INFORMATION:Place of birth: _____Child s Race: African-American Caucasian Native American Hispanic Asian Latino Other(specify) _____Was the child adopted? Yes No If yes, at what age? _____ From where? _____Has the child ever been placed outside of the home? Yes No If yes, where? _____In how many residences has the child lived since birth? _____Has the child been physically or sexually abused, assaulted or molested? Yes No Don t knowIf yes, specify by whom and when: _____Have the child s parents or any other family members had any mental health or emotional problems?

3 Yes No If yes,describe: _____PRESENTING PROBLEM:Briefly describe your child s current difficulties: _____How long has this problem been of concern to you? _____When was the problem first noticed? _____What seems to help the problem? _____What seems to make the problem worse? _____Has the child received evaluation or treatment for the current problem or similar problems? Yes ___ No ___If yes, when and with whom? _____Is the child on any medication at this time? Yes ____ No ____If yes, please note kind of medication: _____How do you want your child s situation to be different after coming here? _____3 For Psychologist Use OnlyPresenting Problem / history of Problem:Symptoms:Interview / Observation of child: social AND BEHAVIOR CHECKLISTP lace a check next to any behavior or problem that your child currently Has difficulty with speech____ Has frequent tantrums____Has difficulty with hearing____ Has frequent nightmares____ Has difficulty with language____Has trouble sleeping (describe) _____ Has difficulty with vision____ Has blank staring spells____ Has difficulty with coordination____ Rocks back and forth____ Prefers to be alone____ Bangs head____ Does not get along well with other children____ Holds breath____ Is aggressive____ Eats poorly____ Is shy or timid____ Is stubborn____ Has poor bowel control (soils self)____ Is much too active____ Is more interested in things (objects) than in people____ Engages in behavior that could be dangerous to self (describe) _____Describe child s relationship with his / her.

4 Father _____Mother _____Sibling(s)_____Step parent(s) _____OTHER INTERPERSONAL RELATIONSHIPS:How do you describe the child sfriendships: No Friends Only Acquaintances Both acquaintances and close friendsHow many close friends? _____4 Place a check next to any behavior or problem that your child currently Has special fears, habits, or mannerisms_____ Is impulsive (describe) _____ Show daredevil behavior_____ Sucks thumb_____ Gives up easily_____ Is slow to learn_____ Wets bed_____ Other (describe): _____EDUCATIONAL HISTORYS chool: _____Grade:_____Place a check next to any educational problem that your child currently exhibits:CheckCheck_____ Has difficulty with reading_____ Has difficulty with other subjects (please_____ Has difficulty with arithmeticlist) _____ Has difficulty with spelling_____ Has difficulty with writing_____ Does not like schoolIs your child in a special education class?

5 Yes _____ No _____If yes, what type of class? _____Has your child been held back in a grade? Yes _____ No _____If yes, what grade and why? _____Has your child ever received special tutoring or therapy in school? Yes _____ No _____If yes, please describe: _____Has your child ever been suspended or expelled? Yes _____No _____If yes, please describe: _____DEVELOPMENTAL HISTORYD uring pregnancy, was mother on medication? Yes ____ No ____ If yes, what kind? _____During pregnancy, did mother smoke? Yes ____ No ____ If yes, how many cigarettes each day? ____During pregnancy, did mother drink alcoholic beverages? Yes ____ No ____ If yes, what did she drink?_____Approximately how much alcohol was consumed each day? _____During pregnancy, did mother use drugs? Yes ____ No ____ If yes, what kind? _____Were forceps used during delivery? Yes ____ No ____5 Was a Cesarean section performed?

6 Yes ____ No ____ If yes, for what reason? _____Was the child premature? Yes ____ No ____ If so, by how many months? _____What was the child s birth weight? _____Were there any birth defects or complications? Yes ____ No ____ If yes, please describe: _____Were there any feeding problems? Yes ____ No ____ If yes, please describe: _____Were there any sleeping problems? Yes ____ No ____ If yes, please describe: _____As an infant, was the child quiet? Yes ____ No ____As an infant, did the child like to be held? Yes ____ No ____Were there any special problems in the growth and development of the child during the first few years?Yes ____ No ____ If yes, please describe: _____The following is a list of infant and preschool behaviors. Please indicate the age at which your child first demonstrated eachbehavior. If you are not certain of the age but have some idea, write the age followed by a question mark.

7 If you don tremember the age at which the behavior occurred, please write a question response to parent_____Put several words together_____Rolled over_____Dressed self_____Sat alone_____Became toilet trained_____Crawled_____Stayed dry at night_____Walked alone_____Fed self_____Babbled_____Rode tricycle_____Spoke first word_____CURRENT HEALTH INFORMATION:Describe child s health generally: Good Fair Poor Is the child sexually active? No YesList any health problems the child has had:_____6 Doesthe child have: Current immunizations No Yes Which are needed? _____ Any allergies No Yes Specify _____ Nutritional problems No Yes Specify _____ Appetite problems No Yes Specify _____ Sleep problems No Yes Specify _____ A disability or handicap No Yes Specify _____ Contagious or other diseases No Yes Specify _____ Any accidents / injuries No Yes Specify _____ Dental, vision or hearing problems No Yes Specify _____ Any hospitalizations No Yes Specify _____Physician: _____NameCityDate of last contact: ____ / ____ / ____ Reason for last contact: _____SUBSTANCE USE /ABUSE:Please complete the chart belowCategory ofDrugHas childeverused?

8 Currentlyusing?Age atfirst useHow oftendoes childuse?Howtaken?Howmuch?Use last48 hours?WithdrawalsymptomsAlcohol No Yes No YesStimulant No Yes No YesCocaine No Yes No YesTranquilizer No Yes No YesBarbituate No Yes No YesMarijuana No Yes No YesOpiod No Yes No YesHallucinogen No Yes No YesPrescribed No Yes No YesNictine No Yes No YesCaffeine No Yes No YesOther No Yes No YesFAMILY medical history :Place a check next to any illness or condition that any member of the child s family has had. When you check an item, pleasenote the member s relationship to the Relationship to childCheckCondition Relationship to child_____Alcoholism _____Depression _____Cancer _____Learning disability_____Diabetes _____ADHD _____Heart trouble _____Mental Retardation _____Bipolar Disorder _____Other _____Anxiety Disorder _____7 RELIGION/SPIRITUALITY:Religion: Protestant Catholic Buddhist Hindu Jewish Muslim Atheist Agnostic Other:_____LEGAL INFORMATION:Has the child ever:Had difficulty or contact with police?

9 Yes NoAppeared in juvenile conference? Yes NoBeen on probation? Yes NoPlease explain: _____OTHER INFORMATION:What are your child s favorite activities?1. _____2. _____3. _____4. _____5. _____6. _____What activities would your child like to engage in more often than he/she does at present?1. _____2. _____What activities does your child like least?1. _____2. _____What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to eachtechnique that you usually use. There also is space for writing in anyother disciplinary techniques that you techniqueCheckDisciplinary technique_____Ignore problem behavior_____Tell child to sit on chair_____Scold child_____Send child to his or her room_____Spank child_____Take awaysome activity or food_____Threaten child_____Other technique (describe) _____Reason with child_____Redirect child s interest_____Don t use any techniqueWhich disciplinary techniques are usually effective?

10 _____With what type of problem(s)? _____Which disciplinary techniques are usually ineffective? _____8 With what type of problem(s)? _____What have you found to be the most satisfactory ways of helping your child? _____What are your child s assets or strengths? _____PREVIOUSCOUNSELING/ PSYCHOTHERAPY:Has your child ever been in counseling / therapy before? No YesName of ProviderClinicYearDiagnosis/ Problem_____Has your child been prescribed psychotropic medication? No YesMedication: _____Dosage: _____Prescribed by: _____Medication: _____Dosage: _____Prescribed by: _____Medication: _____Dosage: _____Prescribed by: _____Reason: _____Other medications currently prescribed:Medication: _____Dosage: _____Prescribed by: _____Medication: _____Dosage: _____Prescribed by: _____Medication: _____Dosage: _____Prescribed by: _____Reason: _____Check if applicable: Inpatient Day Treatment Substance Abuse Program Psychological Testing Partial HospitalizationExplain any of the above: _____Has the child ever: Made a suicide attempt: No Yes If yes, when?