Child Assessment Form
Name
*
First Name
Last Name
Parent's Email
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
Date
Gender
*
Child's Birthdate
*
School Grade
*
Handed
*
Left
Right
Mixed
Primary concerns
*
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Priority of issues for the client:
#1
#2
#3
#4
In the following sections, if symptoms are indicated, please include additional details in the "Additional Notes / information" field
I understand
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EMOTIONS: please add information in the text box below for each area client struggles with
Anxiety
Depression
Mood swings
Fears
Frustration
Anger
Tantrums
Obsessive worries
Other
Additional notes / information:
*
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Self-concept: How does the child feel about self?
Peers and play: How does the child do with peer interactions?
School: Please indicate which areas the child struggles with and add additional information below:
Teacher complaints
Problems with other students
Homework
Other
Additional notes / information:
*
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Attention and cognitive: Please indicate which areas the child struggles with and add additional information below:
Verbal expression
Reading
Spelling
Writing
Math
Art
Sense of direction
Memory
Other
Additional notes / information:
*
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Concentration and Organization: Please indicate which areas the child struggles with and add additional information below:
Attention
Distractibility
Ability to organize time and space
Impulsivity
Other
Activity Level and Motor Activity: Please indicate which areas the child struggles with and add additional information below:
Over active or under active
Coordination
Accident prone
Sense of self space
Motor tics
Verbal tics
Other
Behaviour: Please indicate which areas the child struggles with and add additional information below:
Uncooperative
Inflexible
Unpredictable
Manipulative
Insensitive to others
Oppositional
Defiant
Aggressive
Other
Additional notes / information:
*
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Values: Please indicate which areas the child struggles with and add additional information below:
Lying
Cheating
Stealing
Not knowing right from wrong
No guilt feelings
Other
Habits: Please indicate which areas the child struggles with and add additional information below:
Compulsions
Sleep
Bedwetting
Nightmares/night terrors
Soiling
Teeth grinding
Eating habits
Awareness of appetite
Food sensitivities
Food cravings
Sugar cravings or reactions
Other
Additional notes / information:
*
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Health: Please indicate which areas the child struggles with and add additional information below:
Frequent illness
Headaches
Stomach ache
Chronic constipation
Allergies
Asthma
Pain
Fainting
Seizures
Hearing problems
Vision problems
Other
Perinatal: Please indicate which areas the child struggles with and add additional information below:
Prenatal stress or injury
Prenatal drug exposure
Difficult labor
Difficult birth
Premature or late birth
Medical problems after birth
Adopted (indicate at what age below)
Other
Additional notes / information:
*
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Growth and Development: Please indicate which areas the child struggles with and add additional information below:
Colic
Sleep problems
Eating problems
Activity level
Attachment
Emotional development
Motor development
Language development
Chronic ear infections
Allergies
Asthma
Other
Physical Traumas: Please indicate which areas the child struggles with and add additional information below:
Head injury
Accidents
High fever
Serious illness
CNS infection
Drug overdose
Poisoning
Anoxia
Stroke
Other
Additional notes / information:
*
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Physiological Traumas and Stresses
Abuse or neglect
Family stress
School stress
Death in the family
Illness
Other
Therapies
Psychotherapy
Physical therapy
Occupational therapy
Educational therapy
Medical treatments
Other
Current medications (including supplements & vitamins):
Past medications (including supplements & vitamins):
Additional notes / information:
*
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Family History: Symptoms
Rows
YES
NO
RELATIONSHIP TO CLIENT
Asthma
Autoimmune: Diabetes, Rheumatoid Arthritis, Lupus, MS, etc
Thyroid
Migraine
Sleep problems
Depression
Manic- Depression
Anxiety
Phobias
Panic Attacks
Motor or Vocal tics
Seizures
Eating Disorders
Addictions
Obsessive Compulsive Symptoms
Speech Problems
Attention Problems
Hyperactivity
Learning Problems
Conduct Problems or Criminal Behavior
Autism spectrum
Schizophrenia
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Should be Empty: