Child Intake Forms
These forms are for gathering clinical information for children establishing care who are 12 years of age or younger. This information is required to conduct the initial assessment. If any section does not apply to the reason for seeking an appointment, please feel free to skip that section. Please answer honestly; this information is confidential. If you have any questions while completing these forms, please call our office at 612-436-0295.
Child Symptom Screener
Please enter the name of the person filling out this form:
First Name
Last Name
What is your relationship to the patient?
e.g. parent, guardian, teacher
Directions for questions 1-55: Each rating should be considered in the context of what is appropriate for the age of the child. When completing these 55 questions, please think about the child's behavior in the past 6 months.
Is this evaluation based on a time when the child
Was on medication
Was not on medication
Not sure?
Rows
Never
Occasionally
Often
Very Often
1. Does not pay attention to details or makes careless mistakes with, for example, homework
2. Has difficulty keeping attention to what needs to be done
3. Does not seems to listen when spoken to directly
4. Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5. Has difficulty organizing tasks and activities
6. Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7. Loses things necessary for tasks or activities (toys, assignments, pencils, or books)
8. Is easily distracted by noises or other stimuli
9. Is forgetful in daily activities
10. Fidgets with hands or feet or squirms in seat
11. Leaves seat when remaining seated is expected
12. Runs about or climbs too much when remaining seated is expected
13. Has difficulty playing or beginning quiet play activities
14. Is "on the go" or often acts as if "driven by a motor"
15. Talks too much
16. Blurts out answers before questions have been completed
17. Has difficulty waiting his or her turn
18. Interrupts or intrudes in on others' conversations and/or
19. Argues with adults
20. Loses temper
21. Actively defies or refuses to go along with adults' requests or rules
22. Deliberately annoys people
23. Blames others for his or her mistakes or misbehaviors
24. Is touchy or easily annoyed by others
25. Is angry or resentful
26. Is spiteful and wants to get even
27. Bullies, threatens, or intimidates others
28. Starts physical fights
29. Lies to get out of trouble or to avoid obligations (i.e., "cons" others)
30. Is truant from school (skips school) without permission
31. Is physically cruel to people
32. Has stolen things that have value
33. Deliberately destroys others' property
34. Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35. Is physically cruel to animals
36. Has deliberately set fires to cause damage
37. Has broken into someone else's home, business, or car
38. Has stayed out at night without permission
39. Has run away from home overnight
40. Has forced someone into sexual activity
41. Is fearful, anxious, or worried
42. Is afraid to try new things for fear of making mistakes
43. Feels worthless or inferior
44. Blames self for problems, feels guilty
45. Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
46. Is sad, unhappy, or depressed
47. Is self conscious or easily embarrassed
Rows
Problematic
Somewhat of a Problem
Average
Above Average
Excellent
48. Overall school performance
49. Reading
50. Writing
51. Mathematics
52. Relationship with parents
53. Relationship with siblings
54. Relationship with peers
55. Participation in organized activities (teams)
Rows
Not at All
Sometimes
Pretty Much
Very Much
All the Time
56. Complains of stomach aches
57. Pouts and sulks
58. Appears happy
59. Unable to make up his/her mind
60. Cries often
61. Moves slowly
62. Complains of headache
63. Demonstrates slow speech
64. Spends more time with adults
65. Talks a lot
66. Spends time alone in room
67. Carefree in spirit
68. Self-critical
69. Finds it difficult to leave parents
70. Enjoys new situations
71. Forgetful
72. Easily frustrated
73. Tires easily
74. Gets angry
75. Hostile to others
76. Sullen
77. Bowel problems
78. Cheerful in nature
79. Nausea or vomiting
80. Temper or outbursts
81. Neat appearance
82. Suicidal thoughts
83. Eats poorly
84. Falls asleep well
85. Refuses to go to school
86. Leaves school - "hooks"
87. Moody or irritable
88. Talks about fear of parents dying
89. Works on tasks enthusiastically
90. Sleeps through the night
91. Awakens in morning earlier than necessary
92. Needs help from adults
93. Generally outgoing
Directions for questions 94-134: Below is a list of sentences that describe how people feel. Read each phrase and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for your child. Then, for each statement, select the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.
Rows
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
94. When my child feels frightened, it is hard for him/her to breathe
95. My child gets headaches when he/she is at school
96. My child doesn't like to be with people he/she doesn't know well
97. My child gets scared if he/she sleeps away from home
98. My child worries about other people liking him/her
99. When my child gets frightened, he/she feels like passing out
100. My child is nervous
101. My child follows me wherever I go
102. People tell me that my child looks nervous
103. My child feels nervous with people he/she doesn't know well
104. My child gets stomachaches at school
105. When my child gets frightened, he/she feels like he/she is going crazy
106. My child worries about sleeping alone
107. My child worries about being as good as other kids
108. When my child gets frightened, he/she feels like things are not real
109. My child has nightmares about something bad happening to his/her parents
110. My child worries about going to school
111. When my child gets frightened, his/her heart beats fast
112. My child gets shaky
113. My child has nightmares about something bad happening to him/her
114. My child worries about things working out for him/her
115. When my child gets frightened, he/she sweats a lot
116. My child is a worrier
117. My child gets really frightened for no reason at all
118. My child is afraid to be alone in the house
119. It is hard for my child to talk with people he/she doesn't know well
120. When my child gets frightened, he/she feels like he/she is choking
121. People tell me that my child worries too much
122. My child doesn't like to be away from his/her family
123. My child is afraid of having anxiety (or panic) attacks
124. My child worries that something bad might happen to his/her parents
125. My child feels shy with people he/she doesn't know well
126. My child worries about what is going to happen in the future
127. When my child gets frightened, he/she feels like throwing up
128. My child worries about how well he/she does things
129. My child is scared to go to school
130. My child worries about things that have already happened
131. When my child gets frightened, he/she feels dizzy
132. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (e.g., read aloud, speak, play a game, play a sport)
133. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn't know well
134. My child is shy
Directions for questions 135-146: Please select "yes" or "no" for each question.
Rows
Yes
No
135. Does your child have thoughts or obsessions about which they can't stop thinking? Obsessions are thoughts, ideas, or pictures that keep coming into your child's mind even though he or she does not want them to.
136. Does your child have compulsions or habits which they can't stop doing? Compulsions are things that your child feels he or she has to do although he or she may know they do not make sense.
137. Has your child ever experienced any of the following traumatic events: natural disaster (e.g., flood, hurricane, tornado, earthquake), fire, explosion, or industrial accident; transportation accident (e.g., car accident, plane crash); physical assault (e.g., being attacked, beaten up); sexual assault (e.g., rape, attempted rape, made to perform any type of sexual act through force or threat of harm); captivity or exposure to a war-zone; life-threatening illness or injury; sudden, unexpected death f or injury to someone close to them; or serious injury, harm, or death to someone else that they have witnessed or caused?
138. Has your child had any unusual experiences such as: hearing voices, seeing visions, having ideas they later found out were not true, mind reading, ESP, thoughts being controlled by others, or seeing things on TV that they think refer to them specifically?
139. Are you concerned your child has been drinking alcohol?
140. Are you concerned your child has been using marijuana, illegal drugs, or prescription medications for non-medical reasons?
141. Are you concerned about your child's overall level of development?
142. Are you concerned about your child's development in the areas of speech and language?
143. Are you concerned about your child's learning development in the areas of mathematics, reading, etc.?
144. Has your child had problems with social interactions (e.g., eye contact, social reciprocity, making and keeping friends); social communications (e.g., delays in language, inability to initiate or sustain a conversation, echoalia); or restricted repetitive and stereotyped patterns of behavior, interests, and activities (e.g., hand or finger flapping; rigid, perseverative play)?
145. Has your child had any problems with enuresis (bed-wetting)?
146. Has your child had any problems with encopresis (fecal incontinence)?
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Does the child have any food sensitivities/allergies?
Yes
No
If yes, please describe:
Has the child tried any dietary modifications?
Yes
No
If yes, please describe (including the results):
Please describe the child's stool pattern, frequency, and consistency (e.g., daily, foul, large, mushy, brown):
Does the child have any food sensitivities/allergies?
Yes
No
Screen for Child Anxiety Related Disorders (SCARED)
Below is a list of statements that describe how people feel. Read each statement carefully and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for your child. Then for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.
Rows
Not True or Hardly Ever True
Somewhat True or Sometimes True
Very True or Often True
1. When my child gets frightened, it is hard for him/her to breathe
2. My child gets headaches when he/she is at school
3. My child doesn't like to be with people he/she doesn't know well
4. My child gets scared if he/she sleeps away from home
5. My child worries about other people liking him/her
6. When my child gets frightened, he/she feels like passing out
7. My child is nervous
8. My child follows me wherever I go
9. People tell me that my child looks nervous
10. My child feels nervous with people he/she doesn't know well
11. My child gets stomachaches at schools
12. When my child gets frightened, he/she feels like he/she is going crazy
13. My child worries about sleeping alone
14. My child worries about being as good as other kids
15. When he/she gets frightened, he/she feels like things are not real
16. My child has nightmares about something bad happening to his/her parents
17. My child worries about going to school
18. When my child gets frightened, his/her heart beats fast
19. He/she gets shaky
20. My child has nightmares about something bad happening to him/her
21. My child worries about things working out for him/her
22. When my child gets frightened, he/she sweats a lot
23. My child is a worrier
24. My child gets really frightened for no reason at all
25. My child is afraid to be alone in the house
26. It is hard for my child to talk with people he/she doesn't know well
27. When my child gets frightened, he/she feels like he/she is choking
28. People tell me that my child worries to much
29. My child doesn't like to be away from his/her family
30. My child is afraid of having anxiety (or panic) attacks
31. My child worries that something bad might happen to his/her parents
32. My child feels shy with people he/she doesn't know well
33. My child worries about what is going to happen in the future
34. When my child gets frightened, he/she feels like throwing up
35. My child worries about how well he/she does things
36. My child is scared to go to school
37. My child worries about things that have already happened
38. When my child gets frightened, he/she feels dizzy
39. My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (e.g., read aloud, speak, play a game, play a sport)
40. My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn't know well
41. My child is shy
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Comprehensive Child Clinical History Form (1/21)
Introductory Information
Parent/Guardian 1
Â
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian 2
Â
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
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Comprehensive Child Clinical History Form (2/21)
Chief Complaint
What issues are you seeking help for at this time?
When did you first notice these issues?
What things did you first notice?
Was the onset:
Sudden
Gradual
Please describe any event(s) or action(s) that you or others think might have contributed to these issues (please be as detailed as possible):
What are your goals for the current treatment/evaluation?
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Comprehensive Child Clinical History Form (3/21)
Current Behavior
Relationships
Problems getting along with family
Problems getting along with peers
Har time talking to peers in some situations
Hard time talking to non-family adults
Difficulty understanding jokes
Poor eye contact
Self-conscious; fear of embarrassment; shy
Uncomfortable socially
Fear of social situations
Sensitive to crowds
Stubborn
Distrustful; suspicious; secretive
Lying; sneaking
Frequent arguing
Oppositional/defiant
Temper tantrums; explosive episodes
Externalizing/disruptive
Acting violently
Fire setting
Rule breaking
Property destruction
Stealing
Cruelty to animals
Running away
Risk taking behavior
Alcohol abuse
Other substance abuse
Abuse perpetrator
Mood
Self-esteem problems
Immaturity
Angry; aggressive
Irritable
Self-destructive/self-abusive behaviors
Suicidal talk/thoughts of killing self
Suicidal behaviors; has hurt or cut self
Depression/depressed mood/sadness
Tearful crying spells
Feeling hopeless, helpless, and/or worthless
Grief; loss
Lack of energy; fatigue
Withdrawn
Lack of motivation
Not enjoying usual activities
Difficulty making decisions
Difficulty planning ahead
Overwhelmed/stressed
Feeling guilty
Moodiness
Moods change quickly
Change in personality
Excessively good/grandiose mood; euphoria
Excess energy
Little sleep but not tired; decreased need for sleep
Racing thoughts; flight of ideas
Blackouts
Hallucinations; delusions
Strange ideas or behaviors
Poor awareness of time
Anxiety
Anxiety
Panic attacks
Obsessions or compulsions
Perfectionism
Rigid/inflexible
Repetitive behaviors
Head banging; rocking
Skin-picking
Hairpulling
Gets frustrated easily
Abuse victim; trauma history
Worried
Fear of bedtime
Nightmares
Language and learning
Stuttering
Involuntary vocalizations
Resistance to school
Learning problems; language problems
Trouble concentrating; memory problems; disorganization
Difficulty following directions
Difficulty getting started on tasks
Difficulty staying on one task for a long time
Difficulty with finishing a task; difficulty completing homework
Distractible; gets easily distracted
Difficulty with transitions
Difficulty listening
Impulsiveness
Bouts of excessive energy; always in motion; excessively fidgety; hyperactive
Talkative
Poor judgment
Poor handwriting
Physical
Tics/twitching
Been pregnant
Had an abortion; partner had an abortion
Sexual problems
Dizziness; seizures
Pain/body complaints
Sensory issues
Blank spells; fainting spells
Bed wetting; soiling
Breath holding
Change in sleep habits; difficulty sleeping; difficulty waking
Change in eating habits/appetite; significant weight changes
Eating problems; overeating; eating too little; eating disorder
Eats paint, paper, etc.
Nail biting; thumb sucking
Toileting problems
Uncoordinated; clumsy using hands; clumsy walking
Frequent urinary accidents
If you have other concerns not listed above, please note them here:
If any of the above behaviors were significant issues which have now gone away, please describe:
Please note the degree of impairment in the childs:
Rows
None
Mild
Moderate
Marked
Extreme
Family relationships
School performance
Friendships/peer relationships
Hobbies/play activities
Daily self-care
Physical health
Eating habits
Sleeping habits
How would you describe the child's conscience?
Normal
Lax
Preoccupied with issues
Please note any important additional information regarding the child's current behaviors:
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Comprehensive Child Clinical History Form (4/21)
Review of Systems
Please look at the list of physical symptoms below and check off any that your child has experienced in the last several days. If they have NOT experienced symptoms in an area, be sure to check "None of the above" for that area.
Constitutional
Chronic pain
Loss of appetite
Increase in appetite
Unexplained weight loss
Weight gain
Fatigue/lethargy
Unexplained fever
Hot or cold spells
Night sweats
Sleeping pattern disruption
Malaise (flu-like or vague sick feeling)
None of the above constitutional issues
Other
Eyes
Eye pain
Eye discharge
Eye redness
Blurred or double vision
Visual change
History of eye surgery
Sensitivity to light
Scotomas (blind spots)
Retinal hemorrhage (floaters in vision)
Amaurosis fugax (feeling like a curtain is pulled over vision
None of the above eye issues
Other
Ears, Nose, Mouth and Throat
Earache
Tinnitus (ringing in ears)
Decreased hearing or hearing loss
Frequent ear infections
Frequent nose bleeds
Sinus congestion
Runny nose/post-nasal drip
Difficulty swallowing
Frequent sore throat
Prolonged hoarseness
Pain in jaw or tooth
Dry mouth
None of the above ear, nose, mouth or throat issues
Other
Cardiovascular
Chest pain
Pacemaker
Palpitations (fast or irregular heartbeat)
Swollen feet or hands
Fainting spells
Shortness of breath with exercise
None of the above cardiovascular issues
Other
Respiratory
Pain with breathing
Chronic cough
Chronic shortness of breath
Chronic wheezing/asthma
Excessive phlegm
Coughing blood
Nocturnal Dyspnea (shortness of breath at night)
None of the above respiratory issues
Other
Musculoskeletal
Swelling in joints
Redness of joints
Other joint pains or stiffness
Muscle pain or cramping
Muscle weakness
Muscle stiffness
Decreased range of motion
Back pain or stiffness
History of fractures
Past injury to spine or joints
None of the above musculoskeletal issues
Other
Gastrointestinal
Excessive flatulence or belching
Diarrhea
Constipation
Persistent nausea/vomiting
Abdominal pain
Heartburn
Difficulty swallowing solids or liquids
Recent loss in appetite
Sensitivity to milk products
Jaundice (yellow skin)
Change in appearance of stool
Blood in stool
Dark/tarry stool
Loss of bowel control/soiling
None of the above gastrointestinal issues
Other
Allergic/Immunologic
Frequent infections
Hives
Anaphylaxic reaction
None of the above allergic or immunologic issues
Other
Endocrine
Severe menopausal symptoms
Cold or heat intolerance
Excessive appetite
Excessive thirst or urination
Excessive sweating
None of the above endocrine issues
Other
Hematologic/Lymphatic
Blood clots
Excess/easy bleeding (surgery, dental work, brushing teeth, scrapes)
History of blood transfusion
Excessive bruising
Swollen glands (neck, armpits, groin)
None of the above hematologic or lymphatic issues
Other
Genitourinary (General)
Loss of urine control (including bed wetting)
Painful/burning urination
Blood in urine
Increased frequency of urination
Up more than twice a night to urinate
Urine retention
Frequent urine infections
None of the above general genitourinary issues
Other
Genitourinary (Women)
Unusual vaginal discharge
Vaginal pain, bleeding, soreness, or dryness
Genital sores
Heavy or irregular periods
No menses (periods stopped)
Currently pregnant
Sterility/infertility
Any other sexual or sex organ concerns
None of the above sex-specific genitourinary issues
Other
Genitourinary (Men)
Slow urine stream
Scrotal pain
Lump or mass in the testicles
Abnormal penis discharge
Trouble getting/maintaining erections
Inability to ejaculate/orgasm
Any other sexual or sex organ concerns
None of the above sex-specific genitourinary issues
Other
Neurological
Paralysis
Fainting spells or blackouts
Dizziness/vertigo
Drowsiness
Slurred speech
Speech problems (other)
Short term memory trouble
Memory difficulties (loss)
Frequent headaches
Muscle weakness
Numbness/tingling sensations
Neuropathy (numbness in feet)
Tremor in hands/shaking
Muscle spasms or tremors
None of the above neurological issues
Other
Integumentary (Skin/Breast and Hair)
Lesions
Unusual mole
Easy bruising
Increased perspiration
Rashes
Chronic dry skin
Itchy skin or scalp
Hair or nail changes
Hair loss
Breast tenderness
Breast discharge
Breast lump or mass
None of the above integumentary issues
Other
Psychiatric
Feeling depressed
Difficulty concentrating
Phobias/unexplained fears
No pleasure from life anymore
Anxiety
Insomnia
Excessive moodiness
Stress
Disturbing thoughts
Manic episodes
Confusion
Memory loss
Nightmares
None of the above psychiatric issues
Other
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Comprehensive Child Clinical History Form (5/21)
Therapy/Treatments/Interventions
Has the child ever received any of the following therapies privately or in school? (Please fill out any that apply):
Psychiatric Treatment
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Psychological Treatment
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Counseling
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Group Therapy
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Family Therapy
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Behavioral Interventions
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Neurofeedback
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Physical Therapy
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Occupational Therapy
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Speech & Language Therapy
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Other
Â
Describe:
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Provider/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
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Evaluations/Assessments
Has the child ever had any of the following assessments/evaluations performed privately or in school? IF APPLICABLE, PLEASE BRING PRIOR REPORT(S) TO YOUR APPOINTMENT. (Please fill out any that apply):
Learning/Academic/IQ
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Psychiatric
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Psychological
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Developmental
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Physical
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Neuropsychological
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Occupational
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Speech & Language
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Audiology
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Neurological (e.g., MRI, CAT scan, EEG, etc.)
Â
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
Other
Â
Describe:
Approximate dates
Inpatient/Outpatient?
Please Select
Inpatient
Outpatient
Evaluator/Facility Name & Contact Information
Describe reasons for going
Describe progress noted
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Previous Diagnoses
Has the child ever been given any of the following diagnoses?
Enter applicable information in the corresponding fields:
Rows
Approximate date
At what age was this first diagnosed?
Comments
ADHD/ADD
Anxiety
Auditory Processing Disorder
Autism Spectrum Disorder or Asperger's Syndrome
Bipolar or Manic-Depressive Disorder
Depression
Developmental delay
Hearing impairment
Learning disability
Non-verbal Learning Disorder (NVLD)
Obsessive-Compulsive Disorder
Oppositional-Defiant Disorder
Pervasive Developmental Disorder (PDD)
Selective Mutism
Sensory Processing/Integration Disorder
Tourette's Disorder
Visual impairment
Please note any important additional information regarding the child's mental health treatment/evaluation history:
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Comprehensive Child Clinical History Form (6/21)
Psychiatric Medication History
Has the child ever taken any medication for psychiatric treatment?
Yes
No
If YES, please fill out the table below to the best of your knowledge:
Rows
Medication Name
Dose
How long? (months)
End Date
Effective?
Side Effects
Reason for stopping?
-
-
-
-
-
-
-
-
-
-
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Comprehensive Child Clinical History Form (7/21)
Medical Conditions and Procedures
Please check off whether the child has ever experienced any of the following and/or complains of any of the following conditions (check all that apply):
Aches or pains
Adenoidectomy
Anemia
Asthma
Braces or other orthodontic appliances
Bronchitis
Chest pain
Chicken pox
Chronic constipation
Cold hands/feet
Cold intolerant
Coma
Concussion
Deformities
Diabetes
Difficulty breathing
Dizziness
Ear infections
Ear tubes
Encephalitis
Failure to grow
Flushing
Frequent colds
Frequent fever
Frequent headaches
Gastrointestinal condition
Genetic condition
Head injury which required medical attention
Heart defects
Heat intolerant
Loss of consciousness
Meningitis
Menstrual problems
Mononucleosis (mono)
Movement problems
Measles
Mumps
Nausea
Numbness in extremities
Obesity
Painful urination
Palpitations
PCOS
Physical trauma
Pneumonia
Poisoning
Rubella
Rubeola
Seizures
Sinus infections
Skin problems
Sleep problems
Stomachaches
Stomach problems
Strep throat
Thrush
Thyroid problem
Tiredness
Tonsillectomy
Trouble with hearing
Trouble with vision
Vomiting
Weakness
Whooping cough
Other
Please describe any of the conditions checked above (including age of the child when the condition, incident, or illness occurred, and how frequently the complaints occur-- where applicable):
Is the child currently under treatment for any of the conditions noted above?
Yes
No
If yes, please describe (including age of child and reasons for procedures, where relevant):
Has the child experienced any other injuries not noted above?
Yes
No
If yes, please describe (including age of child and reasons for procedures, where relevant):
Has the child ever been hospitalized?
Yes
No
If yes, please describe (including age of child and reasons for procedures, where relevant):
Has the child ever had any surgeries or operations?
Yes
No
If yes, please describe (including age of child and reasons for procedures, where relevant):
Has the child ever had a neurological evaluation (e.g., exam, MRI, CAT scan, EEG)?
Yes
No
If yes, please describe (including age of child and reasons for procedures, where relevant):
Please list and describe any other current or past medical diagnoses or conditions:
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Medications
Please list all of the child's current medications and previous medications that were taken for more than one months (include prescription and over the counter):
e.g. Name of medication, dose, reason for taking, effects (if any), name of prescriber
Does the child follow the medication regime?
Yes
No
Not applicable
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Vision
Does the child have any vision or eye problems?
Yes
No
If yes, please describe:
Does the child wear glasses?
Yes
No
If yes, for what reason(s):
Date of last vision screen:
 -
Month
 -
Day
Year
Date
Results of last vision screen:
Hearing
Does the child have any hearing problems?
Yes
No
If yes, please describe:
Date of last hearing screen:
 -
Month
 -
Day
Year
Date
Results of last hearing screen:
Allergies
Does the child have any known allergies to medications, foods, animals, etc.?
Yes
No
If yes, please describe:
Immunizations/Vaccinations
Are the child's immunizations up to date?
Yes
No
Please note any important additional information regarding the child's physical health and/or medical history:
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Comprehensive Child Clinical History Form (8/21)
Menstruation and Pregnancy History
Has the child begun menstruating?
Yes
No
At what age did the child begin menstruation?
Which of these best describe their premenstrual symptoms?
Dysphoria
Cramps
Appetite change
Bloating
Sleep disturbance
None of these
Other
Do they use a method of contraception? (check all that apply)
Intrauterine (e.g., IUD)
Hormonal (e.g., implant, injection, pill, patch, hormonal vaginal contraceptive ring)
Barrier (e.g., diaphragm, male/female condom, spermicide)
Fertility Awareness-based (e.g., natural family planning)
Permanent (e.g., male/female sterilization, infertility)
No method of contraception
Other
Have they ever been pregnant?
Yes
No
If yes, how many times?
Have they ever given birth?
Yes
No
If yes, how many times?
Have they had any miscarriages?
Yes
No
If yes, how many times?
Have they had any abortions?
Yes
No
If yes, how many times?
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Comprehensive Child Clinical History Form (9/21)
Family Mental Health/Social History
Please note if any of the child's family members have experienced and/or been diagnosed with any of the following (check all that apply):
Depression
Bipolar/Manic-Depressive Disorder
Suicide or attempt(s)
Anxiety
Panic Attacks
Obsessive-Compulsive Disorder
Tourette syndrome/Tic Disorder
Autism/Asperger's syndrome/Pervasive Developmental Disorder (PDD)
"Absent Minded Professor" Stereotype
Developmental Delays
ADHD/Attention Difficulties
Hyperactivity (especially as a child)
Schizophrenia
Psychosis or Thought Problems
Learning Disabilities/Difficulties; Reading Disorder/Dyslexia
Kept Back in School
Special Education
Speech Problems (especially as a child)
Bedwetting/Bowel Movement Withholding
Aggressive or Violent Behaviors
Erratic Temper; Moods Quickly Change
Physical or Sexual Abuse
Alcohol Abuse/Dependence
Other Substance Use/Dependence
Social Difficulties
Problems Keeping a Job
Legal Trouble/Problems or Police Contact
Frequently in Trouble as a Child/Teenager
Outpatient Psychotherapy
Inpatient Psychiatric Treatment
Other
If any of the above were checked, please briefly describe:
Which family experienced the selected, what was their relationship to the child, were they biologically related, etc.
Please note any important additional information regarding family mental health and/or social history:
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Comprehensive Child Clinical History Form (10/21)
Family Medical History
Please note if any of the child's family members have experienced and/or been diagnosed with any of the following (check all that apply):
Birth defects
Blood problems
Brain disease
Cancer
Diabetes
Eating disorders
Gastrointestinal problems
Hearing problems
Heart rhythm problems
Hospitalizations
Kidney problems
Liver problems
Movement problems
Neurofibromatosis
Neurological disorder/problems
Other heart problems
Seizures
Speech problems
Sudden cardiac death
Sudden unexplained death
Thyroid disease
Visual problems
Weight-related problems
Other
If any of the above were checked, please briefly describe:
Which family experienced the selected, what was their relationship to the child, were they biologically related, etc.
Please note any important additional information regarding family medical history:
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Comprehensive Child Clinical History Form (11/21)
Prenatal Development and Birth History
Prenatal Development
Please select all that apply to the child's prenatal development
The mother had prenatal care while pregnant with the child
The child was conceived through in vitro fertilization
The mother received medicines to increase fertility
The child was a multiple birth
The mother had previous pregnancies
If so, how many previous pregnancies (not including this child)?
Number of ultrasounds during pregnancy:
Please describe any abnormal findings:
Pregnancy Complications
Please check off any of the complications experienced by the mother while pregnant with the child
Anemia
Bleeding
Chronic Illness
Excessive Vomiting
German Measles
High Blood Pressure
Infection(s)
Injury
Preeclampsia
Premature Labor
RH Incompatibility
Surgery
Threatened Miscarriage
Toxemia
Other
Please describe any of the complications marked above and/or medications prescribed to the mother during pregnancy:
Mother's Health Habits While Pregnant
Did the mother use any of the following while pregant?
Caffeine
Tobacco
Alcohol
Recreational Drugs
Prescription Medication
Other
Please describe any of the items selected above (including types and frequency of usage):
Birth/Delivery/Post-Delivery
Mother's age at time of delivery
Father's age at time of delivery
How long was labor (i.e., how many hours from first contractions to birth)? Please only list the number of hours (for example, "8")
Was the mother under anesthesia during delivery?
No
Local
Spinal
General
Was the child born:
On Time
Early
Late
If early or late, by how many days?
How much did the baby weigh at the time of delivery?
Please enter weight in pounds and ounces
Was the baby normally active?
Yes
No
Please check off any of the following items that pertained to the child during delivery and post-delivery
Abnormal color
Baby did not cry right away
Birth defect
Breeched
Cesarean
Cord around neck
Difficulty breathing
Fetal distress
Induced
Jaundice
Natural childbirth
Needed a respirator
Received oxygen
Received phototherapy
Received transfusions
Seizure
Use of forceps
Other
Please describe any additional complications:
Where was the baby born?
Hospital
Home
Other
If the baby was born in a hospital, how many days was the baby in the hospital after delivery?
Please only list the number of days (for example, "2")
If the baby was born in a hospital, did the mother and baby leave the hospital together?
Yes
No
If no, please provide the reason:
After birth, did the baby stay in:
N/A
Well-baby Nursery
Neonatal Intensive Care Unit (NICU
Other
Please describe any medical problems the child had in the first few days/weeks of life:
Did either parent have significant problems adjusting after the birth (including if the mother had problems with depression)?
Yes
No
If yes, please describe:
Adoption
Was the child adopted?
Yes
No
How old was the child when placed in the adopted parent's care?
Please briefly describe the pre-adoption environment and the circumstances of the adoption:
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Comprehensive Child Clinical History Form (12/21)
Developmental History
Early Development
Please check off any of the items that describe the child in infancy, toddlerhood, and/or preschool:
Active baby
Anemia
Asthma
Bad foot odor
Bed wetting
Chronic sniffles
Constipation
Convulsions
Cradle cap
Defiant
Diaper rash
Diarrhea
Did not enjoy cuddling
Difficult to soothe
Difficulty chewing
Difficulty sleeping
Difficulty sucking
Disconnected socially
Eczema or psoriasis
Excessive tantrums
Excessively irritable
Excessively restless
Failure to thrive
Fears/phobias
Finicky eating
Growing pains
Hyperactivity
Jaundice
Limp
Nightmares
Not calmed by being held; difficult to comfort
Poor muscle control
Poor muscle tone
Poor teeth
Poor weight gain
Sensory issues
Stiff
Stomachaches
Tremors
Under-responsive
Very sweaty
Warts
Other
Was the baby (check all that apply):
Colicky
Breast fed
Bottle fed
On a special diet
If yes to any item above, please describe and specify how long for each:
Please describe any other feeding issues (e.g. sensitivities; textures; reflux; resistance; difficulty swallowing; drooling; etc.):
Was the child an "easy baby" who did not cry easily and was flexible?
Yes, very much so
Yes, pretty easy
Probably about average
No, pretty difficult
No, extremely difficult
When the child was a baby, how was s/he with other people?
Above average
Very wary of strangers, very upset if held by or left with others
Indifferent to strangers, no reaction if held by or left with others
Was the child an active infant/toddler?
Low energy, usually quiet and inactive
Not very active
About average
Quite active
Extremely restless and active, into everything
As an infant/toddler, how insistent was the child when s/he wanted something?
Not insistent at all
Not very insistent
About average
Somewhat insistent
Very insistent
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Developmental Milestones
Please note when the following milestones were achieved (enter years and months in separate columns; for example, if the child achieved a milestone at 2 years and 3 months, enter "2" in the first column and "3" in the second):
Motor Development
Rows
Age - years (optional)
Age - months (optional)
Rolled over
Sat without support
Grasped pencil/crayon
Scribbled with crayon
Crawled
Stood Up
Walked holding on
Walked without holding on
Fed self
Drank from a cup
Dressed self
Tied shoes
Pedaled tricycle
Rode bike
Swam
Language Development
Rows
Age - years (optional)
Age - months (optional)
Babbled
Spoke single words
Spoke two word phrases
Spoke in short sentences
Responded to another person's smile by smiling back
Communicated wants by pointing, gesturing, etc.
Imitated others' behavior
Identified words that rhyme
Started to read
Differentiated left from right
Followed commands
Easily understood by others (not family members)
Toileting
Rows
Age - years (optional)
Age - months (optional)
Trained for urine
Trained for bowels
Please select the child's most recent height percentiles
Don't Know
Below 3rd percentile
3rd-10th percentile
11th-24th percentile
25th-75th percentile
Above 75th percentile
Please select the child's most recent weight percentiles
Don't Know
Below 3rd percentile
3rd-10th percentile
11th-24th percentile
25th-75th percentile
Above 75th percentile
What was the child's age when these percentiles were measured?
Have you or the child's pediatrician ever been concerned about the child's rate of growth, height, or weight?
Yes
No
If yes, please describe:
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Language Development
There have been language development concerns
There have been NO language development concerns
Please check off all of the items that relate to the child's language (check all that apply):
Avoids being read to
Does not enjoy listening to stories
Gets frustrated when explaining things orally
Has a hard time asking for help or making his/her wants and needs known to others
Has a hard time expressing his/her ideas
Leaves off endings (e.g., plurals, -ed) when speaking in sentences
Leaves off small words (e.g., the, is, to) when speaking in sentences
Mispronounces words or leaves off sounds in words
Names things incorrectly
Often asks others to repeat what they have said
Repeats sounds, words, or phrases over and over
Talks around an issue without coming to the point
Trouble finding words s/he wants to use
Unable to follow one step directions
Unable to follow multi-step directions
Unable to remember short messages
Unable to respond correctly to who/what/where/when/why questions
Unable to respond correctly to yes/no questions
Unable to understand what people are saying
Other
Is the child's speech (check all that apply):
Usually soft
Usually loud
Hoarse, breathy, or strained-sounding
Dysfluent (e.g., stuttering)
Filled with "um" and "you know"
Unable to be understood by familiar others
Unable to be understood by unfamiliar others
The child currently communicates using (check all that apply):
Body language
Sounds (e.g., vowels and vocalizations)
Single words
2 to 4 word sentences
Full sentences
Other
Was the child ever recommended to have speech or language therapy?
Yes
No
Has the child ever had speech or language therapy?
Yes
No
If the child has had speech or language therapy, please specify where and when. If possible, please give any information related to goals at that time or currently.
Was the child ever recommended to have occupational therapy (OT)?
Yes
No
Has the child ever had occupational therapy (OT)?
Yes
No
If the child has had occupational therapy (OT), please specify where and when. If possible, please give any information related to goals at that time or currently.
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Sensorimotor Development
There have been sensorimotor development concerns
There have been NO sensorimotor development concerns
Please check off the following items that relate to the child's sensory and motor skills:
Tactile
Has trouble managing personal/physical space
Over sensitive to clothing/textures/foods
Under sensitive to clothing/textures/foods
Visual
Avoids eye contact with others
Did not pass most recent vision screening
Has trouble copying words from the board
Has trouble tracking objects with eyes
Auditory (Sound)
Did not pass most recent hearing screening
Fails to listen or pay attention to what is said to him/her
Has difficulty if 2 or 3 step instructions are given at once
History of frequent ear infections
History of PE tubes in his/her ears
Sensitive to loud sounds (e.g., school bells, sirens)
Talks excessively/doesn't wait for his/her turn
Taste & smell
Has trouble eating different textured foods
Insensitive to noxious smells/tastes
Picky eater
Prefers spicy, sour, or bitter food flavors
Sensitive to noxious smells/tastes
Vestibular (Movement)
Gets carsick easily
Likes rough housing, jumping, crashing games
Loses balance easily
Prefers to be sedentary (on computer/TV) rather than play outside
Muscle Tone
Gets tired easily playing or writing
Seems generally weak compared to other kids
Slouches when sitting on floor/chair
Coordination
Bumps into furniture/people often
Cannot ride a bike
Cannot tie shoelaces
Does not enjoy sports
Has an excessive number of accidents compared to other children
Has difficulty holding a pencil or crayon in 3-point position
Has difficulty playing on playground equipment
Has trouble using both hands together easily (e.g., opening milk carton, water bottle, etc.)
Poor ball skills for P.E.-type activities
Poor handwriting
Seems clumsy/awkward
Has difficulty with sequential tasks (e.g., dressing, buttoning)
Is the child:
Right handed
Left handed
Mixed handed/ambidextrous
Is the child currently physically athletic or coordinated?
No, poorly coordinated and not naturally good at most sports
About average
Yes, very coordinated and naturally athletic
Does the child currently have good fine motor coordination?
No, poorly coordinated in fine motor activities
About average
Yes, very good with fine motor activities
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Toileting
Please check off any of the following difficulties related to the child's toilet training:
Bed wetting after training
Nighttime soiling after training
Soiling accidents during the day
Urine accidents during the day
Please describe any of these difficulties, including frequency:
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Comprehension and understanding
Does the child understand directions and situations as well as other children his/her age?
Yes
No
If no, please explain:
If the child tells a story about a show, event, etc., do you or others have difficulty understanding him/her?
Yes
No
If yes, is it because s/he (check all that apply):
Has trouble finding the right words
Is confused
Is disorganized
Leaves out important information
Loses train of thought
Other
Does the child (check all that apply):
Have trouble remembering things s/he really cares about?
Have difficulty following routines (bedtime, dressing, etc.)?
Frequently lose things or have trouble being organized?
How would you rate the child's level of intelligence compare to other children?
Below average
Average
Above average
Do you have any comments on the child's (check all that apply):
Sexual knowledge or awareness
Gender identity
Sexual orientation
If yes to any of the above, please describe:
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Environmental Exposures
Has the child ever lived near a refinery, polluted area, or in a home with lead paint?
Yes
No
If yes, please describe:
Has the child ever lived in a house that had new carpeting, paint, cabinets, ora ny other refurbishing that seemed to affect the child's health?
Yes
No
Does the child seem particularly sensitive to perfumes, gasoline, or other vapors?
Yes
No
Does the child live in a home with vinyl blinds?
Yes
No
From where does the child's home get water?
City
Well
Don't know
Other
Primary type of heat in the child's home:
Gas
Electric
Heating Oil
Wood Stove
Don't Know
Other
Does the child (check all that apply):
Live in a home around where pesticides, herbicides, or other chemicals are sprayed
Live in a home with a water purification system
Live in a home with an air purifier
Live near high voltage power lines
Live near a refinery
Live near the woods
Live near an industrial area
Live near the water
If the child lives near water, what type of water is it?
River
Ocean
Swamp
Lake
Other
Describe the child's bedroom (curtains, blinds, carpet, feather pillows, etc.):
Describe the flooring in other rooms the child spends time in at home:
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Comprehensive Clinical History Form (13/21)
Current Living Situation
How many people currently live in the child's household? (NOT including the child)
Please provide the following information for household/family members currently living in the child's home and for immediate family members currently living outside of the child's home:
Rows
Name
Name
Name
Name
Name
Name
Living inside or outside of home?
Relationship to Child
Gender
Age in Years
Grade/Job
Please provide the following information about the child's biological parents:
Rows
Mother
Father
Name
Living or deceased?
Age (current or when deceased)
Birthplace
Occupation (current or previous)
Number of hours away from home per day. If not living in the home, leave blank.
What languages are spoken at home? If more than one, please indicate which language is primary within the home.
Please note any important additional information regarding the child's current living situation:
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Family Relationships
Parental Relationships/Parenting
Are the child's parents currently:
Together, but not living together or married
Living together
Married
Separated
Divorced
Other
If other, please describe:
This has been the situation for the child's family/parents for how long? Please enter the years and months (e.g., 2 years and 3 months or 5 years)
If the child's parents are married, describe the current relationship, including any significant marital conflicts:
If the child's parents are separated or divorced, has "parent 1" remarried?
Please Select
Yes
No
If yes, for how long has "parent 1" been remarried? Please enter the years and months (e.g., 2 years and 3 months or 5 years)
If the child's parents are separated or divorced, has "parent 2" remarried?
Please Select
Yes
No
If yes, for how long has "parent 2" been remarried? Please enter the years and months (e.g., 2 years and 3 months or 5 years)
Please list any previous parental marriages/long-term relationships involving the child's parents:
If the child's parents are separated or divorced, is their relationship (check all that apply):
No contact
Minimal communication
Amicable
Conflictual
High conflict (violence, no-contact order, etc.)
If the child's parents are separated or divorced, what are the current custody and visitation arrangements?
The child lives with both parents
Joint custody
Other
If other, please describe:
If joint custody, please describe the arrangements:
Who is the child's primary caregiver?
Who cares for the child when the primary caregiver is away?
What are the current arrangements for the child before and after school?
Who usually disciplines the child?
To what extent do the child's parents agree on parenting issues and discipline (if applicable)?
Never Agree
Rarely Agree
Sometimes Agree
Usually Agree
Always Agree
Which of the following methods of discipline are used with the child (check all that apply):
Loss of privileges
Grounded from peers
Grounded from cell phone
Grounded from TV an/or computer
Made to do extra chore(s)
Spanking or other physical punishment
Time out
Reward chart
Token economy
Contingency management
Other
If other, please explain:
How effective is the method(s) of punishment (usually)?
Very effective
Effective
Somewhat effective
Not effective at all
Please explain how the child tends to respond to discipline:
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Child's Relationships in the Family
Describe the child's relationship with his/her parents, noting if there is conflict and/or if the child has difficulty separating from the parent(s):
Describe the child's relationship with his/her siblings, noting if there is conflict:
Please check off the activities in which the child participates with the family (check all that apply):
Movies
Meals
Conversations
Visits with relatives
Television
Religious/spiritual activities
Games
Sports
Trips
Other
If other, please describe:
Please note any important additional information regarding the child's family relationships:
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Educational History
How old was the child when s/he first attended school?
Were there any problems when the child first started school?
Yes
No
If yes, please describe:
Did the child (check all that apply):
receive early intervention services or attend Head Start
attend day care and/or preschool
attend kindergarten
If yes to any of the above, please describe, including any problems and approximately how many hours per week (if applicable):
In the table below, please list all schools that the child has attended (NOT including the current school):
Rows
School #1
School #2
School #3
School #4
School Name
Grade(s) (e.g., 4th or 6th-8th)
Year(s) (e.g., 2009 or 2012-2015)
Name of the child's current school:
What grade is the child currently in? (e.g., 8th)
What year did the child start this school? (e.g., 2013)
School address:
School phone number:
School email:
School fax number:
Is this a:
Public school
Private school
Other
If other, please describe:
In the next table, please indicate the child's academic performance per year in school:
Rows
Failing
Below average
Average
Above average
Superior
Preschool
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Please describe any significant changes in the child's school performance over the years:
What are the child's current grades or GPA (if applicable)?
If there are poor grades, what do you see as the cause (check all that apply):
Difficulty concentrating
Not turning in completed work
Not doing work
Too anxious
Learning disability
Struggles with content
Other
If other, please describe:
In the next table, please indicate the child's behavioral performance per year in school:
Rows
Poor
Fair
Good
Excellent
Preschool
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
Has the child had any education-related testing or assessment?
Yes
No
If yes, what tests and what were the results?
Does the child have any known learning disabilities?
Yes
No
If yes, please describe:
Has the child ever (check all that apply):
received support/services from the school
received private support/special services
been on an IEP or 504 plan
participated in a gifted and talented program in school
If yes to any of the above, please describe (including the age of the child, the reasons, and any notable changes):
Has the child ever (check all that apply):
had frequent school absences or missed an extended amount of school
repeated a grade
been suspended
refused to go to school
If yes to any of the above, please provide details:
Does the child like school?
Yes
No
Please describe the child's attitude towards school:
What are the child's MOST favorite subjects, sports, and/or activities? What does s/he excel at?
What are the child's LEAST favorite subjects, sports, and/or activities? What does s/he have the most difficulty with?
Please check any of the following that describe the child at school (check all that apply):
Considered "bright but unmotivated"
Daydreams
Difficulties with peers
Difficulty being quiet
Difficulty following instructions
Difficulty getting started on tasks
Difficulty in groups
Difficulty keeping hands to self
Difficulty sitting still
Difficulty staying focused during independent work
Difficulty transitioning to a new task
Distractibility
Does not complete classroom work
Does not do homework
Does not remain seated
Does not speak to peers at school
Does not speak to teachers at school
Excessive time to complete assignments
Fails to check homework
Frequently sent out of class
Has a pattern of highly variable grades
Has achieved less academically than parents or siblings (for age)
Hyperactivity
Impulsive
Interferes with others' tasks
Makes careless mistakes
Meltdowns or tantrums
Messy and disorganized
Noncompliant in class
Not wanting to go to school
Oppositional with teachers
Poor at math
Poor at spelling
Poor attention
Poor handwriting
Poor reader
Requires additional supervision
Skips school
Talks inappropriately
Test anxiety
Too withdrawn or passive
Upset when leaving parents
Works too quickly
Works too slowly
Written language difficulties
Please note any important additional information regarding the child's educational history:
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Social History
Please describe the child's overall current social skills and peer relationships:
Please describe how you think the child interacts with peers while at school:
Would you describe the child's social support as:
Poor
Fair
Good
Excellent
Are you satisfied with the child's social situation?
Yes
No
Is the child satisfied with his/her social situation?
Yes
No
Does the child (check all that apply):
have a best friend or friends
have difficulty initiating activities with peers
get into frequent conflicts/fights with peers
have difficulty making friends
have difficulty keeping friends
have difficulty getting along with adults
seem interested in having friends
have friends that are a poor influence
get invited to extracurricular activities (e.g., birthday parties, play dates)
show an interest in getting to know other children when in a new setting (e.g., park, party)
spend the night away from home
The child plays/interacts with children that are (check all that apply):
the same age
younger
older
Does the child seem to miss social cues (e.g., not understanding when s/he is being teased, not understanding humor, not recognizing when children are disinterested in what s/he is talking about, perceives hostility when there is none)?
Yes
No
If yes, please describe:
Has the child been bullied/teased?
Yes
No
If yes, please describe:
Has the child bullied other children or been aggressive in play with others?
Yes
No
If yes, please describe:
Please note any important additional information regarding the child's social history:
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Lifestyle Health
Being as descriptive as possible, please describe the child - what is he/she like? Describe his/her temperament, strengths, and interests:
Daily Living
Please select the best description of the child with respect to the following daily functions:
Rows
Needs a lot of help
Needs some help
Needs no help
Getting dressed
Eating
Bathing
Getting food, etc.
Chores/cleaning
Sleep
What is the child's overall level of sleep quality?
Poor
Fair
Good
Excellent
How many hours of sleep does the child get during a typical night?
What time does the child usually go to sleep? Please enter in the following format: 00:00am/pm (e.g., 7:30pm)
What time does the child usually wake up? Please enter in the following format 00:00am/pm (e.g., 8:30am)
Does the child have standard bedtime routines or rituals?
Yes
No
If yes, please describe:
Does the child sleep in the parents' room:
Not at all
Some of the night
All of the night
If the child sleeps in the parents' room, please rate how concerned you are about this:
Not at all
Mildly
Moderately
Extremely
Please check off the following items that relate to the child's sleep:
Bed wetting
Bedtime behavior problems
Can't sleep alone
Chronic "night owl"
Chronically tired from inadequate sleep
Difficulty falling asleep
Difficulty staying asleep
Frequent wakening
Grinds teeth
Naps during the day
Nightmares
Nighttime cough frequently
Restless sleeping
Sleep apnea
Sleep walking
Snoring
Takes medicine in order to sleep
Very heavy sleeper
Very light sleeper
Waking too early
Other sleep issues
If you selected "other sleep issues", please describe:
Describe any past or present concerns/difficulties regarding the child's sleep patterns:
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Nutrition/Eating
Please indicate if the child has had recent significant weight change:
Weight loss
Weight gain
Neither Weight Loss nor Weight Gain
Describe the child's appetite and diet:
Please check off the following items that relate to the child's diet/eating (check all that apply):
Mostly baby foods
Mostly meat
Mostly carbohydrates (bread, pasta, etc.)
Mostly vegetarian
Mostly dairy (cheese, milk, yogurt)
Eats too little
Eats too much
Excessively picky eater
Strong aversion to eating textured foods
Takes very long time to eat meals
Other diet/eating issues
If you selected "other diet/eating issues", please describe:
Does the child have any food sensitivites/allergies?
Yes
No
If yes, please describe:
Has the child tried any dietary modifications?
Yes
No
Please describe the child's stool pattern, frequency, and consistency (e.g., daily, foul, large, mushy, brown):
If yes, please describe (including the results):
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Extracurricular Activities
Please describe how the child generally spend her/his free time (e.g., plays alone, plays with friends, plays sports, watches TV, plays video games):
What extracurricular activities, sports, and/or other special interests does the child engage in (inside or outside of school)? Also, please describe how well you feel the child does in these areas:
Please list any additional organizations, clubs, teams, or groups in which the child participates:
Does the child get regular exercise?
Yes
No
Please describe:
Please list the approximate number of hours per day that the child: (For each item below, please only list the number of hours; for example, "2") Watches the TV
Plays video games
Is on the computer
Is outdoors
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Substances
To you knowledge, has the child ever used any of the following (check all that apply):
Rows
Never
In the Past (Suspected)
In the Past (Confirmed)
Current (Suspected)
Current (Confirmed)
Caffeine (frequent use only; in any form - including cola drinks)
Tobacco (in any form)
Alcohol
Prescription medication(s) to get high
Recreational drug(s) (including marijuana)
If other, please describe:
If yes to any, please list types and briefly describe the child's use of each (including frequency/amount):
Please not any important additional information regarding the child's lifestyle health:
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Legal History
Has the child ever had any police contact or legal problems?
Yes
No
If yes, please describe:
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Trauma/Stressors
Please indicate if the child has experienced any of the following significant events:
Rows
Yes or No?
Date (month(s) when this occurred (optional)
Date (year(s)) when this occurred
Age of child when this first occurred (years)
Age of child when this first occurred (months) (optional)
Physical or emotional separations from caregivers
Divorce of caregivers
Death of family member(s) or other significant person(s)
Physical trauma/abuse
Sexual trauma/abuse
Emotional trauma/abuse
Neglect
Exposure to violence, drugs, or sexually explicit material
A significant move or moves
An accident
Illness or injury
Accident, illness, or injury of family member(s) or other significant person(s)
Family financial difficulties or job loss
Other significant stressors in the family environment (including marital stress)
If other, please describe:
If yes to any of the above, please briefly describe:
How does the child handle stress?
Please note any important information regarding trauma/stressors in the child's life:
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Spiritual Orientation
Please describe the spiritual orientation or religion of the child's family:
How active are spiritual beliefs/religion in the family's life?
Not at all active
Somewhat active
Very active
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Caregiver Comments
Please note any additional information about the child that you want to share:
Should be Empty: