• Child & Adolescent Assessment Information Packet

    Please fill out the form to the best of your knowledge. If some questions are not applicable to your child, write N.A.
  • Date of birth:*
     / /
  • Length of time at current residence:*
  • Type*
  • Type
  • Type:*
  • Type:
  • Mother/Guardian's legal relationship to child:*

  • Father/Guardian's legal relationship to child:*

  • If child is adopted, give legal date of adoption:
     / /

  • II. Referral Information

  • Primary reason(s) for seeking assessment:

  • Has child had a psychological assessment in the past?

  • Which of the following are current concerns:

  • Difficulties with Impulse Control
  • Difficulties with Attention/Concentration
  • Difficulties with Defiance/Disobedience
  • Difficulties with Social Life
  • Difficulties with Memory
  • Difficulties with Academic Performance
  • Depression or Anxiety

  • III. Previous Evaluations

    For each category, please list any previous evaluations, examiners, dates, and results.

  • Health

  • Date of last physical exam:
     / /

  • Psychological

  • Date of last evaluation:
     / /

  • Occupational Therapy/Physical Therapy:

  • Date of last evaluation:
     / /

  • Vision/Hearing:

  • Date of last examination:
     / /

  • Neurological:

  • Date of last examination:
     / /

  • IV. Previous Services

    Please list any previous therapy or special services your child has received inside or outside of school:
  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • Dates of service:
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  • IV. Pregnancy

    List all of mother's pregnancies in order, including the client. If a pregnancy ended in miscarriage, state at which month.
  • Rows
  • Was child planned?
  • Rows
  • Any tobacco use, alcohol use, or drugs taken by the mother during pregnancy?
  • History of maternal illness
  • Any hospitalizations during pregnancy
  • Any threatened miscarriage or early contractions
  • Method of delivery
  • At time of delivery, baby was:

  • Any birth complications
  • Any maternal complications before discharge?

  • IV. Developmental History

  • How was baby typically fed?
  • Describe baby's response to feeding:

  • What type of feeding schedule was used:
  • Any concerns with feeding (e.g., poor suck, reflex)?
  • Were there times when the baby had frequent spells of colic, constipation, or diarrhea?
  • Describe baby's activity levels during the first few months of life:
  • During the first year of life, was there anything that placed the mother or father under special strain?
  • Were there any periods when the child habitually awoke crying and any periods in which s/he had to be held or rocked in order to fall asleep?
  • Motor Milestones
  • Can child tie own shoes?
  • Can child ride a bike?
  • Can child dress him/herself?
  • Which hand does your child prefer?
  • Did your child ever have any motor coordination difficulties (e.g., confusion about left or right handedness, frequent falling, awkwardness, etc?
  • How does your child perform athletically
  • Speech/Language milestones:
  • Other languages besides English growing up
  • Any concerns with speech problems (e.g., stuttering, is difficult to understand)?
  • Any concerns with oral-motor problems (e.g., late drooling, poor sucking, poor chewing)?
  • Any current concerns with bed-wetting, urine accidents, or soiling?

  • VII. Medical History

  • Rows
  • Has your child ever been hospitalized?
  • Has your child ever had surgery?
  • Does your child have any hearing or visual defect?
  • Does your child consume caffeine?
  • Do you have any concerns with child's diet/eating habits?
  • Rows
  • Does your child frequently complain of:

  • Is your child taking any medication?
  • Rows
  • Other special medical test?

  • Family Medical History 

  • Rows
  • Does any disease run in the family?

  • VIII. Behavior and Social History

  • People living in the same household as the client:

  • Client’s brothers or sister living outside the home:

  • Have there been or are there currently conflicts:

  • Between the parents:
  • Between the parents and child?
  • Between the children
  • Does the child seem to have a closer attachment to one parent than the other?
  • Have any of the child's caretakers been accused of child neglect or abuse?
  • Has your child ever experienced or observed a traumatic event?
  • Does your child have difficulty getting along with children his/her age?
  • Does your child have difficulty getting along with adults?
  • Does your child prefer playing with :
  • What methods have you used in disciplining?

  • Is frequent discipline necessary?
  • Have there been any recent stressful life events?

  • During the early years of the child's life, was either parent frequently away or out of the house (e.g., business trips, hospitalizations, etc. ?
  • Does the child have any expressed fears (e.g., the dark, dogs, etc.)?
  • Has the child ever lost any person with whom s/he seemed to have a close relationship (e.g., mother, father, sister, etc.)?
  • Has the child ever seemed reluctant or objected to being left in the care of others?
  • Did the child have any pre-school experiences during which separation from home or a significant other was difficult for him/her?
  • Rows
  • Has the child ever had angry outbursts, temper tantrums, or other kinds of behavior that caused you to feel concern?
  • Has the child's parents participated in family therapy or received "parent training"?
  • Check the item(s) that describe your child:
  • Does your child have or ever had:

  • IX. School History

  • Has your child participated in any testing at school?
  • Has your child ever been retained in one or more grades?
  • Has your child ever skipped a grade?
  • Is your child receiving any special services (e.g., IEP or 504 plan)?
  • How much time does your child spend studying?
  • What best describes your child's grades through his/her schooling thus far:
  • Describe your child's attitude toward school when s/he first started:
  • Describe your child's current attitude toward school:

  • Reading

  • Any concerns with reading (at home and/or at school)?
  • Any concerns with child's ability to read aloud?
  • Does your child enjoy reading for pleasure?

  • Writing

  • Any concerns with writing (home and/or school)
  • Does writing seem especially difficult/challenging for him/her?
  • What is the quality of his/her handwriting?
  • What is the quality of his/her spelling?
  • What is the quality of his/her story writing?

  • Mathematics

  • Any concerns with mathematics (home and/or school)?
  • Any concerns with the following?

  • X. Additional Information

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  • Should be Empty: