Child-Client Information Package

Child Client Information

For Children up to 16 Years Old
Today's Date:

MonthDayYear
Date
Child's First Name:
Child's Last Name:
DOB:
Age:
Phone Number (### ###-####)

Area CodePhone Number
Type of Phone:
Address:
Number and Street
City
State
Zip Code
Email:
example@example.com
Additional Contact:
Name
Relationship
Area CodePhone Number
Email: example@example.com
Additional Contact:
Name
Relationship
Area CodePhone Number
Email: example@example.com
Additional Contact:
Name
Relationship
Area CodePhone Number
Email: example@example.com
Messages
If we call you, may we leave a message with someone else?
May we leave a voicemail message?
May we send appointment reminders?
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?
*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?

Other
Today's Date:

MonthDayYear
Date
Handedness:
Which of these has your child experienced?
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?
Does your child typically sleep through the night, except for getting up to go to the bathroom?
Does your child wake feeling rested?
Comments about your child's sleep:
Is your child sensitive to caffeine? (Chocolate, cola, tea, coffee)
Caffeine makes my child:
Is there any history of using recreational drugs?
If yes, explain
Do you have any psychiatric or mental health diagnoses?
If yes, explain:
Have there been any hospitalizations related to psychiatric or mental heal issue?
If yes, explain:
Is there a history of any suicidal thoughts or thoughts of self-harm?
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:
Comments about the help you utilzed:
Any IEP or 504 plan or accommodations?
Greatest strengths:
Any developmental or other early relevant history:
PHYSICAL:
# 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?
Siblings?
Friends and peers?
Teachers?
Enter any comments regarding the 4 relationships above:
ACADEMICS: Is your child doing well academically?
ACADEMICS: Is your child behind grade level in: (check all that apply)
ACADEMICS: Are there other subjects your child struggles with more than others?
Does your child avoid activities?
If yes, explain:
Does your child have difficulty shifting from one activity to another (transitioning)?
How would you describe your child?
Does your child have healthy self-esteem?
Does your child have excessive sensitivity to light/sound/noise?
Should be Empty:

Child Client Information

Messages

Sleep Patterns:

Child History

Does your child get along well with...