Comprehensive History of Child/Teen

1

Name of child/teen* This field is required.

First Name

Last Name

2

What is the name of your child's therapist?* This field is required.

Veronica Vaiti

Amir Levine

Claire Corbetta

Eliana Panora

Rachel Kimelman

Emily Shapiro

Amanda Veras

Amanda Sacks

Cayley Kasten

Melissa Dominguez

Maria Del Rosario

Alyssa Kushner

Anginese Philips

Nancy Gershman

Glendenise McPherson

Bailey Brown

Nitin Kini

3

Full name of individual filling out this form and individual's relationship to child/teen* This field is required.

4

Mother's name

First Name

Last Name

5

Fathers name

First Name

Last Name

6

Step-mother's name (if applicable)

First Name

Last Name

7

Step-father's name (if applicable)

First Name

Last Name

8

Guardian's name (if applicable)

First Name

Last Name

9

Relationship of guardian to child/teen if not parent or step-parent (if applicable)

10

Has your child/teen ever been placed in a psychiatric hospital?* This field is required.

Yes

No

11

If you said Yes to the previous question, please provide dates of hospitalization and reasons:

12

Has your child/teen received therapy/counseling in the past?* This field is required.

Yes

No

13

If you said Yes to the previous question, please provide more information including if it was helpful, names of any previous therapists, approximate dates of attendance, and reasons for attendance:

14

Has your child/teen previously taken any medications for emotional/behavioral problems?* This field is required.

Yes

No

15

If you said Yes to the previous question, please describe:

16

Please provide a list of the current individuals living in the same home as the child/teen including the age of each individual, the relationship of each individual to the child/teen, and any additional information about the child’s family that would be useful for the therapist to know (ie, family/marital conflict, alcohol/drug abuse, health/medical conditions, financial distress/loss of job):* This field is required.

17

Describe your child’s academic performance over the past school year:* This field is required.

Good

Fair

Poor

18

If you selected Poor for the previous question, please explain more:

19

Is your child’s behavior a problem in his/her school?* This field is required.

Yes

No

20

If you selected yes for the previous question, please describe:

21

Does your child have any chronic illnesses, genetic illnesses, allergies or handicaps?* This field is required.

Yes

No

22

If you selected yes for the previous question, please describe:

23

Was the mother's pregnancy with the child/teen

Planned

Unplanned

24

Describe whether the experience of pregnancy on the mother was favorable/unfavorable...

25

Did any trauma occur during the pregnancy or soon after birth? If yes, please describe

26

Was pregnancy...

Full term

Premature

Late

27

Describe delivery (ie, smooth, complicated, c-section):

28

Was your child born with a low/average/high birth weight and height:

29

Was your child exposed to prenatal drug use? Yes/No If yes, what kind

30

Did mother experience postpartum depression?

Yes

No

I dont know

31

Describe when your child/teen first: babbled, sat unassisted, rolled over, crawled, walked, said first words (what were they and age), talked, and become potty trained:

32

Are the child/teen's biological parents:

Married/living together

Married/living apart

Not married/living together

Not married/living apart

Separated/Divorced

33

How long has this been the arrangement?

34

Age of child/teen at time of separation/divorce:

35

Are the child/teen's biological parents still living?

Yes

No

36

If No, age of child when parent died:

37

Length of relationship with step-parent/legal guardian

38

Describe the relationship between mother and child/teen:

39

Describe the relationship between father and child/teen:

40

Describe the relationship between siblings and child/teen:

41

Describe the relationship between step-parent or legal guardian and child/teen:

42

Have there been any significant events in your child’s life in the past 12 months?

Yes

No

43

If you answered Yes to the previous question, please describe:

44

Does your child have difficulties in any of the following areas? weight loss/gain, mood swings, bed wetting, diet/eating, frequent crying, nightmares, uses drugs/alcohol, depressed, waking up/going to bed, caffeine/nicotine, suicidal ideations/attempts, irritability? Please describe in more detail here:

45

Does your child have difficulties in any of the following areas? soils pants, lying/exaggerating, getting along with other kids, sucks thumb, cruelty to animals, getting along with other adults, motor skills, fascination with fire/weapons, dating, language skills, sexual acting out, nervous habits, truancy, involvement with law enforcement? Please describe in more detail here:

46

Describe your child’s fears:

47

How does your child show affection?

48

How does your child show anger?

49

What are some of your child’s favorite activities?

50

Describe the discipline techniques of the mother, father, step-parent, and any other caregiver:

51

As far as you are aware, has the child ever been physically abused?

Yes

No

52

As far as you are aware, has the child ever been sexually abused?

Yes

No

53

As far as you are aware, has the child ever been emotionally abused?

Yes

No

54

As far as you are aware, has the child ever been neglected?

Yes

No

55

If you responded Yes to any question about abuse or neglect, please explain more (ie: what was your child’s reaction to the abuse/investigation/outcome)

56

Please use this space to share any additional information that could be useful in helping us learn about your child and/or family and in developing a treatment plan for your child and/or family:

57

Your signature below indicates that the information you have provided in this document is accurate to the best of your knowledge, and may be used in providing therapeutic treatment for your child/teen/family: * This field is required.

Clear

58

Date* This field is required.

Date