CHILDREN psychosocial2020

CHILDREN'S PSYCHOSOCIAL

CLINICAL ASSESSMENT

Date:

Child's full name:

Birthdate:

Age:

Nickname, if any:

Gender:

Preferred Pronouns:

Street Address Line 2

Parent or guardian completing this form:

Address:

Street Address Line 2

Phone:

Email*

example@example.com

Parent's name, if different from above parent:

Address:

Phone Number

Please enter a valid phone number.

Email

example@example.com

State in your own words the nature of your child's main problem:

1. Specifically why is the child being referred? Please state the questions you would like answered.

2. Specific background information or behavior that led to the referral?

3. When did the problem start?

4. Was there anything that happened at the time the problem began that might be related to the difficulty?

5. What has been your biggest concern relative to your child's physical and emotional development thus far?

6. Has your child experienced anything unusual or traumatic?

Additional comments, treatment expectations and concerns of parents:

Previous psychological treatment:

Please list any therapists and agencies that your child has been in treatment with (inpatient or outpatient) as well as the dates he/she was in treatment along with the reason for treatment. Agency Dates Reason for treatment Helpful?

Health history: Indicate age, severity and after effects.

Measles

High fevers

Chicken pox

Whooping cough

Mumps

Allergies

Scarlet fever

Hay fever

Tuberculosis

Asthma

Meningitis

Nerve disorder

Kidney disease

Tonsillitis

Frequent colds

Paralysis

Muscle disorder

Cerebral palsy

Seizures

Ear ache

Epilepsy

Overweight

Eye problems (double vision)

Tongue tie clip

Hearing problems (ringing)

Underweight

Poisoning

Staring spells

Fainting spells

Head injury

Memory issues

Suicide attempts

Does anyone in the family have a history of the previous or any other illnesses or handicaps? If so, please explain:

Medications:

Right handed

Left handed

Does your child appear to be overly bothered by:

Loud noises

Smells

Light

Textures/clothing

Are immunizations up to date?

Any reactions?

Name of family's or child's physician:

Please describe any serious accidents or operations the child has had:

Has your child ever had any of the following evaluations?

Psychological

Where

When

Speech

Where

When

Hearing

Where

When

Eye

Where

When

Neurological

Where

When

Physical

Where

When

Does your child have any handicaps (visual, auditory, speech, language, muscular)? If so, please explain:

Is the child adopted?

If yes, at what age?

Did you receive prenatal care?

If yes, at which month did you first see a doctor?

During this pregnancy, did the mother have any unusual illnesses, conditions, or accidents? (such as German measles, false labor, spotting, swelling or water retention, toxemia, RH incompatibility, diabetes, etc?) If so, please describe:

Any exposure during pregnancy to toxic chemicals?

Any medications taken during pregnancy? If so, which?

How would you describe your overall mental health and physical health during pregnancy?

Hours of labor:

Was labor induced?

Length of pregnancy: (full term, premature, or post mature?)

Delivery: (C section, instruments used, easy, difficult, normal?)

Did child's head or feet come first?

Birth weight:

Were you awake?

Length:

blue?

jaundiced?

bruised or scarred?

Other?

Were there any sucking or swallowing problems?

Were there any breathing problems?

Any feeding problems?

Was there any difficulty during infancy with attachment or bonding between you and your child?

Developmental history

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

Held head up

Sat alone

Crawled

Pulled up to standing

Walked alone

Breast fed to age

Bottle fed to age

Self weaned?

Used a spoon

fork

Drank from a glass/cup

Ate solid food

Special diet needs?

Babbled

Used gestures meaningfully

Single words

Phrases

Day

Night

Complete sentences

Training started

Training finished

Day

Night

Training Started

Training finished

Daytime accidents to age

Nighttime accidents to age

How did the child's growth compare to that of their siblings?

Appetite:

Does your child have a good appetite?

How many meals does your child eat each day?

Is there excessive snacking?

Excessive sugar eaten?

Does your child have an aversion to certain types of food?

Sleeping habits:

Usual number of hours of sleep

Naptime

Bedtime

Time child goes to bed

Time child wakes up in the morning

Does your child seem to require a lot of sleep (more than 12 hours a day) or little sleep (less than 8 hours a day)

Where does your child usually sleep (crib, junior bed, adult bed):

Does your child sleep alone?

Does your child sleep well?

Does your child have a routine at bedtime?

Any sleeping problems?

Juvenile history:

Has your child ever been arrested or appeared in Juvenile Court?

Has your child ever been removed from your care and placed in foster care?

Family history:

Mother's name:

Birthdate:

Date

Occupation:

State of health:

Father's name:

Birthdate:

Date

Occupation:

State of health:

Are both parents in the home?

Separated or divorced?

Death of a parent?

Visits by other parent?

Step parent?

Foster parent?

Age of child at time of divorce or death, if applicable:

Age of child at remarriage

Length of present marriage

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

Name Birthdate Age Grade Areas of difficulty in school

Others living in home:

Social development:

How does your child get along in the home?

How does your child get along with mother?

Father?

Brothers?

Sisters?

Adults?

Strangers?

Children child's own age?

Younger?

Older?

Pets?

Do you see any changes occurring?

Any strong attachment outside of the home?

Time spent watching TV each day

Does your child dress itself?

How much help do they need?

Ever put wrong arm in sleeve?

Selects their own clothes?

Can child leave the yard?

Permission required?

What kind of toys and play does your child like the most?

By self

With others

Shares well?

Does your child help with simple jobs, like picking up toys?

What chores does your child have?

Does your child share feelings easily?

Pain?

Anger?

Any fears, please describe:

Any nursery school experience?

What does your child like to do for fun?

Very active

Frequent accidents

Loses balance easily

Very calm, quiet

Restless

Unusual walk

Difficulty sitting still

Nervous or tense

Affectionate

Good natured

Easily angered

Cries easily

Frequent mood changes

Grew rapidly

Grew slowly

Rocks body back and forth (sitting)

Long periods of little or no growth

Rocks body while standing

Uncontrolled facial jerks

Difficulties chewing or swallowing

Speech difficulties: describe

Clumsy or awkward

Poor eating habits: describe:

Excessive talkativeness

Frequently ill

Separation anxiety

Suicidal ideations

Homicidal ideations

Discipline:

What type of discipline do you use most often?

Talk with child

Physical

Persuasion

Reasoning

Taking away privileges

Other

Who disciplines most?

Agreement on discipline?

Any big changes in discipline methods by you or others?

Do you have problems with management or controlling your child?

Describe your child's reactions to discipline (does it work?)

Current grade level in school

Last term

Now

Current goals in school

Special education?

Has your child ever been held back or skipped a grade?

Which grade?

What was the reason:

Any problems in school behavior reported to you by teachers?

Any suspensions?

When?

How does your child get along with children in school?

Has your child ever gotten into trouble due to stealing?

Drugs/alcohol?

Has your child ever been in trouble for threatening other students?

Signature of parent/guardian

Date

Please answer the following questions in regard to your child:

Birth and prenatal history:

After birth was the child:

Bladder control

Bowel control

Personal characteristics:

School

Average grades received