Child Client Information
For Children up to 16 Years Old
Today's Date:
*
/
Month
/
Day
Year
Date
Child's First Name:
Child's Last Name:
Male
Female
DOB:
Age:
Phone Number (### ###-####)
-
Area Code
Phone Number
Type of Phone:
Cell
Landline
Address:
Number and Street
*
City
*
State
*
Zip Code
*
Email:
example@example.com
Additional Contact:
Name
Relationship
-
Area Code
Phone Number
Email: example@example.com
Additional Contact:
Name
Relationship
-
Area Code
Phone Number
Email: example@example.com
Additional Contact:
Name
Relationship
-
Area Code
Phone Number
Email: example@example.com
Messages
If we call you, may we leave a message with someone else?
Yes
No
May we leave a voicemail message?
Yes
No
May we send appointment reminders?
Text
Email
Both
None
Goals for your child’s training or primary problemsyou’d like to see addressed:
Other providers helping with these issues (please provide contact details)
HOW DID YOU HEAR ABOUT US?
*Medical Professional
*Mental Health professional
Friend or acquaintance
Facebook
Internet Search
Article or ad
Psychology Today
Center for Brain Training website
Informational seminar
*If medical or mental health professional, please provide name, city, state
List all prescribed medications/how long on them?/comments
List all supplements/OTC medications/how long on them?/comments
Child's First Name:
Child's Last Name:
What brings you here today?
ADHD
Attention Issues
Anxiety
Sleep
Behavior or mood
Processing or cognitive difficulties
Other
Today's Date:
/
Month
/
Day
Year
Date
Handedness:
Right
Left
Ambidextrous
Which of these has your child experienced?
Hit head
Concussion
Been in car or bike wreck
None
More explanation:
Sleep Patterns:
What time does your child typically fall asleep?
How long does it take your child to fall asleep? (minutes/hours)
Does your child wake up easily?
Yes
No
Sometimes
Never or almost never
Does your child typically sleep through the night, except for getting up to go to the bathroom?
Yes
No
Sometimes
Never or almost never
Does your child wake feeling rested?
Yes
No
Sometimes
Never or almost never
Comments about your child's sleep:
Is your child sensitive to caffeine? (Chocolate, cola, tea, coffee)
Yes
No
Unknown
Caffeine makes my child:
Alert/awake
Jittery/wired/hyper
Relaxed
No effect
Is there any history of using recreational drugs?
Yes
No
If yes, explain
Do you have any psychiatric or mental health diagnoses?
Yes
No
If yes, explain:
Have there been any hospitalizations related to psychiatric or mental heal issue?
Yes
No
If yes, explain:
Is there a history of any suicidal thoughts or thoughts of self-harm?
Yes
No
If yes, explain:
Child History
Child's First Name:
Child's Last Name:
Provide any important family history related to the child (divorce, disruptions in family, loss of family, adoption, foster, etc.)
History of help utilized:
Counseling or behavioral therapy
Occupational Therapy
Tutoring
Speech
Medications
Special diets or nutrition
Comments about the help you utilzed:
Any IEP or 504 plan or accommodations?
Greatest strengths:
Any developmental or other early relevant history:
PHYSICAL:
Headaches
Stomach issues
Constipation
# of rounds of antibiotics in child's life:
Does your child get along well with...
This applies to the next 4 questions
Parents/step-parent/guardian?
Yes
No
Sometimes
Siblings?
Yes
No
Sometimes
Friends and peers?
Yes
No
Sometimes
Teachers?
Yes
No
Sometimes
Enter any comments regarding the 4 relationships above:
ACADEMICS: Is your child doing well academically?
Yes
No
ACADEMICS: Is your child behind grade level in: (check all that apply)
Reading
Math
Spelling
Other subjects
Not Behind
ACADEMICS: Are there other subjects your child struggles with more than others?
Does your child avoid activities?
Yes
No
If yes, explain:
Does your child have difficulty shifting from one activity to another (transitioning)?
Yes
No
How would you describe your child?
Does your child have healthy self-esteem?
Yes
No
Does your child have excessive sensitivity to light/sound/noise?
Yes
No
Submit
Should be Empty: