• CHILDREN'S PSYCHOSOCIAL

    CLINICAL ASSESSMENT

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  • Please answer the following questions in regard to your child:

  • Health history: Indicate age, severity and after effects.

  • Does your child appear to be overly bothered by:

  • Has your child ever had any of the following evaluations? 

  • Birth and prenatal history:

  • After birth was the child:

  • Developmental history

    State the age at which your child did these things: (Is this from memory or record?) 

  • Bladder control

  • Bowel control

  • Appetite:

  • Sleeping habits:

  • Juvenile history:

  • Family history:

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  • Brother and sisters: Please list all children including step and half siblings. Please check (X) the name if they live outside the home.

  • Social development:

  • Personal characteristics:

  • Discipline:

    What type of discipline do you use most often?

  • School

  • Average grades received

  • Clear
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  • Should be Empty: