Child Identification Information
Name of child: B-Date:
Siblings names / ages in birth order:
Parent work phone:
Emergency contact & phone number:
Referral source (“How did you get my name?”):
Days and times preferred:
Current school & grade:
Financial information: How will you be paying for services (circle: Cash, Credit, Check)
Child Developmental History
Please fill in any information you have on the areas listed below (Only if relevant)
Pregnancy and delivery outcome:
Prenatal medical illnesses and health care:
Was the child premature? Weight and height at birth:
Any birth complications or problems?
The first few months of life
Sleep patterns or problems:
Personality or temperment:
Milestones: Any delays in the following (Sitting without support, crawling, walking, dressing, toilet trained, eating with utensils, stayed dry at night, dressing, language development, other …..)
Any speech, hearing, or language difficulties, or developmental delays?
List all childhood illnesses, hospitalizations, medications, allergies, head trauma, important accidents and injuries, surgeries, periods of loss of consciousness, convulsions/seizures, and other medical conditions.
Condition Age Treated by whom?
Any residential placements, institutional placements, special schools, or foster care Dates
Reason for placement
Special skills, talents of interests of child:
List hobbies, sports; recreational, TV, and toy preferences; etc.:
- Unusual Weight changes
- Headaches (location, type, )
- Dizzy Spells, Seizures, Petit Mal Seizures, Neurological Concerns
- Gait & Coordination problems
- Sensory Difficulties (vision, smell, hearing, proprioception)
- Personality Changes (mood, behavior, anxiety, apathy, hyperactivity)
- Head Traumas, accidents, toxic exposures, infections
- Birth Defects
- Genetic History (familial)
- Immunity (frequent colds, flus, )
- Elimination health (diarrhea, constipation, nausea, enuresis, encopresis)
- Muscle twitching, tics, movement d/o
- Handedness (left / right)
- Ability to concentrate and attend
- Behavior (compliant, bossy, defiant, )
- Temperment (current)
- Drooping of facial muscles or eyelids
- Range of motion of head
- Strengths and weaknesses (physical and mental)
- Strange behaviors
- Dietary habits and typical meals
- Behavioral changes related to time of day, season, weather, environment
- Family Dynamics and environment
- Neighborhood and school environment
- Post-traumatic stress or traumatic event exposure
- Ability to relate to peers and adults
- Anxiety (social, school, phobias, obsessive compulsive d/o, separation, etc.)
- Parent-child interaction
- Eating disorders (pica, malnutrition, anorexia)
Treatment: Has your child ever received psychological or psychiatric or counseling services before? No Yes
When? From whom? For what? With what results?
Has your child ever taken medications for psychiatric or emotional problems? No Yes
When? From whom? Which medications For what With what results?
Current medication Dosage How long have you been taken this medication
Date of your child’s last physical exam, general health:
Current Medical / Psychological and other health care providers
Name Specialty Address Phone # Date of last visit
Chief concern : Please describe the main concern you have with your child at this time:
When did your child’s problems begin?
What was happening just prior to the time that may have contributed to the current problems?
Who is involved or affected by this problem? How are they involved?
What have you tried so far to handle the problem?
What has worked? When is it worse – when is it better?
Have there been any previous episodes of this problem? If so, what brought the problem on & how did you resolve it?
Does your child smoke (how much), drink, use drugs, caffeine, : Please Indicate:
How does your child feel about school?
How is your child’s relationships with peers, spouse, children, family
What can I do for you? How can I be of assistance?
How long will it take? How will we both know when we are successful?