Children’s Mental Health Child/Adolescent Diagnostic ...

1 Page 1 of 8 children s Mental Health Child/Adolescent Diagnostic assessment (TO BE COMPLETED BY PARENT/CAREGIVER)PART 1 Please provide the following information in preparation your interview with your Mental Health NAME (FIRST, MI, LAST)CLIENT NUMBERREFERRAL SOURCEREASON FOR REFERRAL_____Living situationParent s Home l RENT l OWNR esidential Care/Treatment Facility** l HOSPITAL l TEMPORARY HOUSING l RESIDENTIAL CARE l NURSING HOMEO ther** l FRIEND S HOME l RELATIVE/GUARDIAN S HOME l HOMELESS**IDENTIFY PERSON S NAME OR FACILITYP rimary HouseholdHousehold member nameRelationship to childAgeOccupation/SchoolHighest level of education Quality of relationshipSTREET ADDRESS (If different from child s address listed on Demographic Information form.)

2 DHS-5704A-ENG 6-09 Page 2 of 8 Does the client live in more than one household? l NO If no, skip to Additional Family Members l YES If yes, complete the secondary household information HouseholdHousehold member nameRelationship to childAgeOccupation/SchoolHighest level of education Quality of relationshipSTREET ADDRESS (If different from child s address listed on Demographic Information form.)Family members who live in both households l ONLY child l child and (list): _____Additional family members l NO, parents or sibling other than those listed in primary or secondary households l YES, list family members: _____Custody and parenting plan l LIVES WITH BOTH PARENTS (biological or adoptive) in same household l SINGLE PARENT l SHARED CUSTODY parents in different households l OTHER (describe): _____ _____Developmental issuesHave you ever had concerns about the following issues with this child ?

3 PregnancyYesNoUnknownHad bleeding during first three (3) monthslllHad bleeding during second three (3) monthslllHad bleeding during last three (3) monthslllHad toxemialllHad to take medications Specify any medication: _____ _____lllGot injured or hurtlllGained less than 15 lbs. (7 kgs.) Specify: _____lllTook narcotic drugslllDrank alcohollllHad an infectionlllPage 3 of 8 Smoked during pregnancylllLength of pregnancy: _____ monthslllOther pregnancy problems/illnesses Specify: _____ _____lllBirth/Early InfancyYesNoUnknownBorn prematurelylllBorn with cord around necklllInjured during birthlllHad trouble breathinglllTurned blue (cyanosis)lllWas a twin or tripletlllHad an infectionlllHad seizures (fits, convulsions)lllNeeded oxygenlllWas very jitterylllChildhood Health IssuesYesNoUnknownIf yes, age first noted If yes, still occurring?

4 Seizures (convulsions) or spellsllllHigh fevers (over 103 F. or 39 C.)llllHead injuryllllAsthmallllTrouble with hearingllllTrouble with visionllllLead poisoningllllOther poisoning or overdosellllOther serious illnessllllOther hospitalizationsllllFunctioningYesNoUnkn ownIf yes, age first noted If yes, still occurring?Poor appetitellllConstipationllllStomach achesllllTrouble falling asleepllllTrouble staying asleepllllOveractivityllllHead bangingllllRocking in bedllllTemper tantrumsllllPage 4 of 8 Self-destructive behaviorllllDifficulty in being comforted or consoledllllStiffness or rigidityllllLooseness or floppinessllllCrying often and easilyllllShyness with strangersllllIrritabilityllllExtreme reaction to noise or sudden movementllllAttention problemsYesNoUnknownIf yes, age first noted If yes, still occurring?

5 Can concentrate for only a short time unless things are very interestingllllUnderstand the main ideas of things but misses important detailsllllDoes work or performs many tasks carelessly without thinkingllllLearns a new skill well one day and then can t seem to do it a few days laterllllReceives very unpredictable (inconsistent) grades or test scores in schoolllllCan work well only on things he/she really enjoys doing or thinking aboutllllOften doesn t notice when he/she makes mistakesllllSeems not to realize when he/she is disturbing someonellllDoesn t do much better after punishment or correctionllllMakes comments about or is distracted by background noises or unimportant thingsllllSeems to want things right away and/or is hard to satisfyllllAnnoys or bothers other childrenllllBehavior is variable and hard to predictllllIs a troublemaker; bullies othersllllBehaviorsYesNoUnknownIf yes, age first noted If yes, still occurring?

6 Has bad dreams llllIs often very quiet or withdrawnllllIs often down on himself/herselfllllIs often tiredllllSpeaks unclearly, stutters, or stammersllllWets bed or pants oftenllllSoils underwear or has accidents with bowel movementsllllIs often too neat or orderlyllllIs often too concerned about cleanlinessllllPage 5 of 8 Often plays with matchesllllDestroys objects at homellllDestroys objects away from homellllIs fearlessllllIs cruel to animalsllllIs not liked by other children llllFeels ill on school morningsllllHas eating problems (either overeats or undereats)llllIs preoccupied with food or dietllllIs part of a clique or gang that causes troublellllOther behaviors not noted abovellllHave you ever had concerns about your child s early development ( walking, talking, learning)?

7 LlllHave you ever had concerns about your child s sexual development or behaviors?llllIF THERE ARE INDICATIONS OF ISSUES, PLEASE EXPLAIN_____Child s school functioningEducation classificationDoes your child receive special education services? l YES l NO If no, has your child ever been tested and determined not to need services? l YES l NORegular education classroom, no special services l YES l NO If no, check all that apply below. l Early Childhood Spec. Delay l Special learning disability l Special Learning Disability l Autism Spectrum Disorder l Hearing Impaired l Traumatic brain injury l Visually Impaired l Other Health impaired l Speech or Language Impaired l Unsure l Physically Impaired l Current 504 plan l Emotional/Behavioral Disorder l Other: _____ l Developmental/Cognitive Disability _____COMMENTS ON EDUCATIONAL CLASSIFICATION_____Page 6 of 8 child s legal historyDoes your child have a history of legal charges?

8 L NO l YESIF YES, DESCRIBE CHARGES_____Is the child currently on probation? l NO l YESHas the child ever been on probation? l NO l YESHas the child ever been court-ordered into chemical Health or Mental Health treatment? l NO l YESC hild s trauma historyChildren s Protective Services (CPS) involvement with family l NO l YESIF YES, DESCRIBE_____NAME OF CPS CASEWORKER(S) ASSIGNED TO FAMILY (IF APPLICABLE)l NONE REPORTEDNAME OF GUARDIAN AD LITEM (GAL) OR COURT APPOINTED SPECIAL ADVOCATE (CASA) ASSIGNED TO FAMILYl NONE REPORTEDHas your child ever experienced any of the following? l Physical abuse l Domestic violence/abuse l Physical neglect l Emotional abuse l Sexual abuse/molestation l Community violence l None of the aboveChild s Mental Health treatment historyPrevious Mental Health treatment l NO l YES If yes, please list reason for treatment, and dates:ReasonDatesCurrently on any medication(s)?

9 L NO l YES IF YES, PLEASE LIST AND BRING MEDICATIONS TO NEXT APPOINTMENT_____Page 7 of 8 PRIMARY CARE PHYSICIANPHONE NUMBERADDRESSCITYSTATEZIP CODEOTHER PRESCRIBING PHYSICIAN(S)PHONE NUMBERADDRESSCITYSTATEZIP CODEC hild s alcohol and drug historyDo you have any concerns about your child s use of alcohol or drugs? l NO l YES Do you have any other issues or concerns about your child you would like to have addressed? l NO l YES COMMENTS_____Family Environment/RelationshipsPlease indicate below the best descriptions of parent- child (Client) Relationship(s) P = Primary household S = Secondary household B = BothParent- child conflict_____ NONE MILD_____ MODERATE_____ SEVEREI ssues with supervision and monitoring of child_____ ALWAYS_____ USUALLY_____ INCONSISTENTLY_____ RARELYC ooperation between parents regarding child -rearing_____ ALWAYS_____ USUALLY_____ INCONSISTENTLY_____ RARELY_____ NOT PERTINENTP arent positive activities with child_____ FREQUENT_____ OCCASIONALLY_____ INFREQUENTP arent satisfaction with relationship_____ SATISFIED_____ NEUTRAL_____ DISSATISFIEDC hild satisfaction with relationship_____ SATISFIED_____ NEUTRAL_____ DISSATISFIEDCOMMENT ON PARENT- child RELATIONSHIPS (describe further if needed)_____Please indicate below the best descriptions of sibling- child (Client)

10 Relationship(s) l NO SIBLINGS P = Primary household S = Secondary household B = BothChild-sibling conflict_____ NONE MILD_____ MODERATE_____ SEVERES ibling(s) positive activities with child_____ FREQUENT_____ OCCASIONAL_____ INFREQUENTS ibling(s) satisfaction with relationship_____ SATISFIED_____ NEUTRAL_____ DISSATISFIEDC hild satisfaction with relationship_____ SATISFIED_____ NEUTRAL_____ DISSATISFIEDCOMMENT ON SIBLING- child RELATIONSHIPS (describe further if needed)_____Page 8 of 8 Please indicate below the best descriptions of parent marital or couple Marital or Couple Relationship(s) l NOT APPLICABLE P = Primary household S = Secondary household B = BothMarital or couples conflict_____ NONE MILD_____ MODERATE_____ SEVEREM arital or couples satisfaction_____ SATISFIED_____ NEUTRAL_____ DISSATISFIEDCOMMENT ON PARENT MARITAL OR COUPLES RELATIONSHIPS (describe further if needed)_____Other Family ConcernsIf yes, indicate.