Child & Family Information Form
Date Form Completed
/
Month
/
Day
Year
Date
Clinician to complete the assessment or treatment (if known)
Dr Antonia Forster
Dr Michael Fulop
Kevin Tomlin. MA, LPC
Dr Greg Cox
Other
Person Completing Form
First Name
Last Name
Relationship to Patient
Please Select
Mother
Father
Stepmother
Stepfather
Guardian
Self
Other
Person completing form email
Phone for person completing form
Ok to include you in our follow-up surveys about your satisfaction?
Please Select
YES
NO
Child, Teen, or Patient's Name
First Name
Last Name
Child, Teen, or Patient Initials
Child, Teen, or Patient's DOB
/
Month
/
Day
Year
Date
Child, Teen, Patient's Gender
Please Select
Female
Male
Other
Do no want to say
Child, Teen, Patient's School
Child, Teen, or Patient's Grade
Please Select
KG
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12
College Freshman
College Sophomore
College Junior
College Senior
College Unspecified
Community College
Graduate School
Medical School
Other
Teacher's Name:
School Address
Are parents divorced?
Yes
No
Is custody joint?
Yes
No
If custody IS NOT joint list non-custodial parent
First Name
Last Name
Non-custodial parent email & phone
Child or Teen is
Right Handed
Left-Handed
Mixed-Handed
Ambidextrous
When developed hand preference
Age 1-2
Age 3-4
Age 4-5
Age 5 +
Child or Teen is Adopted
Yes
No
If adopted, list age
If adopted, give details when, where, prenatal, postnatal care levels.
Times moved since child was born
0
1-2
3-4
5-6
>6
Child/Teen attends religious services
Yes
No
Religious Affiliation
Who referred you to us?
First Name
Last Name
Referral source phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Check services interested in for child teen or emerging adult.
Therapy
Comprehensive Assessment
Limited Assessment
Homework Coaching
In Home Services
Consultation
Other
Goals for assessment, therapy, or coaching.
Check areas you think need to be a focus of assessment or treatment.
Reading
Mathematics
Written Skills
ADHD
Other Learning
Executive Skills
ASD Spectrum
Anxieties
Depression/Mood
Clarify Diagnoses
Documentation of Dx's
School Accommodations
Test Accommodations
Behavioral Issues
Homework Coaching
Failure to Launch
Parent Training
Help with T1 Diabetes
Eating Disorders
Weight Management
Other
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Page 2 - Child & Family Info Form
Continued
Your current and past concerns about your child/teen...
Please check ANY or all of your CURRENT or PAST concerns for your child/teen
Not minding
Whining
Defiance
Bickering/Arguing
Lying
Stealing
Aggression
Hitting
Lack of Friends
Friend Choices
Bullying Others
Bullied by Others
Temper tantrums
Rage Episodes
Disorganization
Forgetfulness
Memory Probs
Losing Pers Items
Nightmares
Night Terrors
Excess Scrn Time
Excess Gaming
Excess Soc Med
Headaches
Stomachaches
Overeating
Poor Appetite
Moodiness
Frequent Crying
Low Self-Esteem
Giving up Easily
Oft Discouraged
Overly Active
Lack of Exercise
Perfectionism
Neg Self-Talk
Nightmares
Insomnia
Often Sleeping
Sleeps Little
Drug Use
Alcohol Use
Tobacco Use
Obsessions
Repetitive Behs
Ritual Behaviors
Sexual Behaviors
Enuresis
Encopresis
Eating issues
Self Harm
Suicide ideation/acts
Other
Child/teen frequently loses personal items [check all that apply]
Hats
Coats
Gloves
Books
Book Bags
Glasses
Sports Equipment
Computer
Phone
Other
Please use this space to further explain any of your CURRENT or PAST concerns
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Family Members & Others living in the home
Rows
Name
Age
Grade in School or Education Level
Job
Race
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Others Living
in Home
Others Living
in Home
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Early Developmental History
Anything unusual occur for patient or mother during pregnancy, labor, or delivery...
Yes
No
If yes to the previous question, please elaborate.
Did birth mother smoke, drink, or use drugs during pregnancy?
Yes
No
If yes to the previous question, please elaborate.
My child/teen required special or extra care as a newborn or infant...
Yes
No
If yes to the previous questions, please elaborate.
Birth Weight & Birth Length & APGAR
In infancy was child/teen...[all]
Predictable with sleep
Predictable eating
Easily soothed?
Other
What was most enjoyable about your child as a newborn or infant
What was most difficult about your child as a newborn or infant
My child attained all developmental milestones within normal limits
Please Select
Yes
No
Noted via next question
Notes about things affecting you or your child's growth, development, starting school...
Month when your child sat unsupported
Month was Bladder Trained
Months Child/teen Was Bowel Trained
Month Child/Teen had dry bed
Month walked unsupported
Month first words heard
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Health Care History
Previous Illnesses your child has experienced
Celiac Disorder
Headaches
Concussion
Drug Allergies
Drug Reaction
Encephalitis
Growth Problems
Hearing Problems
LD Diagnosis
Meningitis
Migraine HA
Freqnt Earaches
Freqnt Resp Inf
Seizures
Tiring Easily
T1 Diabetes
Type 2 Diabetes
Vision Problems
Stomachaches
Other
Diagnosis age and salient details about previous illnesses listed above
Physician or Pediatrician
Physician/Pediatrician Phone
Psychiatrist/MH Practitioner
Email for Psychiatrist/MH
Does or has your take medications regularly? If so, please check all
Adderall
Adderall XR
Concerta
Cylert
Cymbalta
Dexedrine
Effexor
Focalin
Intuniv
Prozac
Ritalin
Methylphenidate
Tenex
Vyvanse
Wellbutrin
Other
Dosage, and prescribers for medications listed above.
Behaviors, Habits, Emotion Regulation
Psychological Treatment History
No Previous Treatment
Outpatient Treatment
Intensive OP Treatment
Inpatient Treatment
Individual Treatment
Drug & Alc Treatment
Family Therapy
CBT/ACT
DBT
Behavior Therapy
Medications
Exposure Therapy
Residential Treatment
Wilderness Treatment
Other
Details on checked items from previous [who-when-intensity-length-treatment]
Has your child/teen experienced any of these issues, or problems?
Physical abuse
Sexual abuse
Run away from home
Arrested or adjudicated
Set a fire
Assaulted someone
Destroyed property
Hurt self
Threatened to hurt self
Threatened others
Used a weapon
Used alcohol /drugs
Used tobacco
Grades dropped lots
Had tutors/Ed Specialists
Sexually active
Cruelty to animals
Rituals or compulsions
Rigidity in Thinking
Shyness
Social Problems
Other
Please give further important details on any checked items above:
MOTHER - Percent of time your child/teen follows your requests
FATHER - Percent of time your child/teen follows your requests
Amount child/teen warrants discipline
Never
Not very often
Not often
Sometimes
Often
Very Often
Describe situations in which your child or teen warrants discipline
What types of discipline seem effective with your child
Ignoring
Spanking
Rewards/Incentives
Lecturing
Natural Consequences
Yelling
Time Outs
Work Chores
Nothing seems to work
Other
Any other comments about ANY behaviors or emotion regulation problems.
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School & Learning History
Schools Your Child has attended [Add row, or please include Pre-KG and pre-schools]
Has Your Child/Teen been classified as... [check all that apply]
Reading Disability
Speech Disability
Language Disability
Math Disability
Severe Emotional Disability
Executive Skill Disability
Other Health Impaired
T1 Diabetes
ADHD
Other
Is child/teen currently on an IEP
Yes
No
Is child/teen now on a 504 plan
Yes
No
Present Accommodations if on IEP/504
My child/teen has time in resource room
Yes
No
Grades child/teen had SPED, IEP, or 504
Pre-KG
KG
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Additional comments or details about your child or teen's learning problems
Child/teen had psych testing in school
Yes
No
If yes to psychological testing in school, when and at what school
Has child/teen been seen by a school counselor
Yes
No
If seen by counselor, why
Child/teen skipped grades
Yes
No
Child/teen repeated grades
Yes
No
If child/teen repeated or skipped a grade, please give us the details
Has your child or teen's grades changed recently
Please Select
Getting a lot better
Getting slightly better
Have Stayed the Same
Getting slightly worse
Getting a lot worse
Child/teen's grades last term
Child/teen's current GPA
Child/teen has past/current behavior probs in school
Yes
No
Details for current/past behavior school problems for child or teen
Child/teen has problems with peers at school
Yes
No
Details of current or past problems with peers at school
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Homework & Schoolwork Habits
How many minutes child/teen spend on daily homework
Please Select
None
0 - 30 minutes
30 minutes - 1 hour
1 - 2 hours
2 - 3 hours
3 - 4 hours
4+ hours
How many minutes do you/others spend on homework with child/teen
Please Select
None
0 - 30 minutes
30 minutes - 1 hour
1 - 2 hours
2 - 3 hours
3 - 4 hours
4+ hours
Difficulty your child/teen has staring hw.
Very easy, a self-starter
Easy
Neutral
Hard
Very hard, most times
Homework completion, handing in
Completes & hands in homework often
Often complete, but not turned in
Often neither completes, or hands in
Other
Comments/notes about homework, schoolwork, studying, or academic performance
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Family & Extended Family Health History
Please check whether ANY relatives have had any of these types of problems [Explain in the next text box].
*
Rows
Mother's Family
Father's Family
Learning Problems
Reading Problems
Alcohol Abuse
Drug Abuse
Legal Problems
Inattention Issues
Hyperactivity
Mood Problems
Depression
Bipolar Disorder
Mental Retardation
Obsessions or Compulsions
Perfectionism
Tics/Involuntary Movements
Anger Problems
Anxiety Problems
Social Anxiety
Emotional Regulation
Executive Skills Issues
Psychosis/Schizophrenia
No Mental Health or Learning
problems in extended family
Explain or detail checked items above
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Child/Teen's Favored Activities, Entertainment, Strengths
Child/teen's favorite activities
Child/teen has a best friend
Yes
No
Child/teen has regular friends at school
Yes
No
Child/teen has regular friends at home
Yes
No
Child/teen has problems making or keeping friends
Yes
No
Child/teen has troubles getting along with siblings
Yes
No
Child/teen has trouble getting along with teachers or adults
Yes
No
Comments on friendship and sibling relationships.
Things you like to do together
Your child/teen's strengths
What your family likes to do together
How often you read to your child
How often your child/teen reads on their down
number of minutes or hours per week
Hours child/teen watches TV/ streams on most weekdays
Hours per day or week
Hours child/teen watches TV on weekends?
Hours per weekend
Hours child/teen plays computer games on typical week days?
Hours per day
Hours your child plays computer games on a typical weekend day?
Hours per weekend
My child/teen has problems regulating screen time
Yes
No
I've had to limit access to screen time for my child or teen
Yes
No
Does your child/teen practice anything?
Yes
No
What does he/she like to practice
Does your child/teen play an instrument or any type of musical training?
Yes
No
What instrument or musical activity [how often, how intensely, etc]
Aerobic exercise minutes child/teen gets each week
Does your child engage in sports regularly; if so, please check...
Baseball
Basketball
Cross Country
Dance
Fencing
Field/Track
Football
Golf
Gymnastics
Hiking
Hockey
Lacrosse
Martial Arts
Rock Climbing
Rugby
Running
Skiing
Snowboard
Soccer
Softball
Swimming
Tennis
Volleyball
Water Polo
Running
No Sports
Dislikes competing
Dislikes team sports
Other
What extracurricular activities or hobbies does your child or teen do?
Any other information you think we should know about your child or teen?
Please give further information or details about your therapy/assessment goals?
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