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Comprehensive History of Child/Teen
Hi there, please fill out and submit this form only if you have been asked to do so by your assigned therapist Thank you so much!
58
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1
Name of child/teen
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First Name
Last Name
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2
What is the name of your child's therapist?
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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
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3
Full name of individual filling out this form and individual's relationship to child/teen
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4
Mother's name
First Name
Last Name
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5
Fathers name
First Name
Last Name
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6
Step-mother's name (if applicable)
First Name
Last Name
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7
Step-father's name (if applicable)
First Name
Last Name
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8
Guardian's name (if applicable)
First Name
Last Name
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9
Relationship of guardian to child/teen if not parent or step-parent (if applicable)
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10
Has your child/teen ever been placed in a psychiatric hospital?
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Yes
No
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11
If you said Yes to the previous question, please provide dates of hospitalization and reasons:
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12
Has your child/teen received therapy/counseling in the past?
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Yes
No
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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:
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14
Has your child/teen previously taken any medications for emotional/behavioral problems?
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Yes
No
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15
If you said Yes to the previous question, please describe:
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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):
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17
Describe your child’s academic performance over the past school year:
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Good
Fair
Poor
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18
If you selected Poor for the previous question, please explain more:
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19
Is your child’s behavior a problem in his/her school?
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Yes
No
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20
If you selected yes for the previous question, please describe:
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21
Does your child have any chronic illnesses, genetic illnesses, allergies or handicaps?
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Yes
No
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22
If you selected yes for the previous question, please describe:
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23
Was the mother's pregnancy with the child/teen
Planned
Unplanned
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24
Describe whether the experience of pregnancy on the mother was favorable/unfavorable...
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25
Did any trauma occur during the pregnancy or soon after birth? If yes, please describe
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26
Was pregnancy...
Full term
Premature
Late
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27
Describe delivery (ie, smooth, complicated, c-section):
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28
Was your child born with a low/average/high birth weight and height:
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29
Was your child exposed to prenatal drug use? Yes/No If yes, what kind
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30
Did mother experience postpartum depression?
Yes
No
I dont know
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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:
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32
Are the child/teen's biological parents:
Married/living together
Married/living apart
Not married/living together
Not married/living apart
Separated/Divorced
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33
How long has this been the arrangement?
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34
Age of child/teen at time of separation/divorce:
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35
Are the child/teen's biological parents still living?
Yes
No
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36
If No, age of child when parent died:
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37
Length of relationship with step-parent/legal guardian
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38
Describe the relationship between mother and child/teen:
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39
Describe the relationship between father and child/teen:
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40
Describe the relationship between siblings and child/teen:
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41
Describe the relationship between step-parent or legal guardian and child/teen:
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42
Have there been any significant events in your child’s life in the past 12 months?
Yes
No
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43
If you answered Yes to the previous question, please describe:
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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:
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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:
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46
Describe your child’s fears:
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47
How does your child show affection?
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48
How does your child show anger?
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49
What are some of your child’s favorite activities?
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50
Describe the discipline techniques of the mother, father, step-parent, and any other caregiver:
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51
As far as you are aware, has the child ever been physically abused?
Yes
No
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52
As far as you are aware, has the child ever been sexually abused?
Yes
No
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53
As far as you are aware, has the child ever been emotionally abused?
Yes
No
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54
As far as you are aware, has the child ever been neglected?
Yes
No
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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)
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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:
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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:
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Clear
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58
Date
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Date
Month
Day
Year
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