Child & Family Assessment Tool
Shine Your Light, Christian Coaching & Consulting Services - Linda Sheppard, MS, FLE, PhD ABD
Child's Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
Gender
*
Please Select
Female
Male
Transgender
Other
Prefer not to say
Age
*
Parent's Name
*
First Name
Last Name
Email
*
example@example.com
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Occupation
*
Referred By:
*
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Presenting Problem
Describe the family and child's problem(s) that brings you to Shine Your Light?
*
Check any of the symptoms that you are having:
Depressed
Extreme sadness
Physical complaints of pain
Change in sleeping habits
Bedwetting/soiling
Change in eating habits
Problems getting along with family
Anger outbursts
Low self-esteem
Perfectionist
Worries
Feels fearful
Running away
Has hurt or cut themselves
Feels hopeless
Tearful/crying spells
Memory problems
Lack of energy
Stuttering
Problems getting along with friends
Feelings of extreme happiness
Truancy
Irritability
Isolation/withdrawal
Expresses feelings of guilt
Seems nervous
Sudden feelings of panic
Tense/uptight
Thoughts of killing self
Thoughts of killing others
Acting violently
Harm to animals
Parent/family goals:
*
History of Treatment
Has the child been in treatment before?
*
Please Select
Yes
No
If Yes, please give dates and the name of the person who saw for treatment
Was the treatment successful?
Please Select
Yes
No
What happened?
Was the child's school/counselor part of the treatment?
Please Select
Yes
No
If Yes, what was their involvement?
School Counselor Name
First Name
Last Name
Counselor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Has the child been prescribed any psychiatric medications?
*
Please Select
Yes
No
If Yes, give the date and name of medication prescribed
Substance Abuse History
Does the child use:
*
Rows
Current Use
Suspected Use
Past Use
Never Used
Comments
Tobacco (any form)
Alcohol
Caffeine (any form, including cola drinks)
Recreational drugs
Psychological History
*
Rows
Yes
No
Comments/Explanations
Has the child witnessed violence?
Has the child been traumatized or abused?
Was the child a victim, victimizer, or both?
Was there a dominance of big kids over little kids that organized the orphanage or home?
Has there been any family crisis since the adoption? (Loss of family member, marital separation, divorce etc)
Do you know of any mental health issues in the family of origin?
Is the child aggressive?
Does the child struggle with impulse control?
How did/does the child attempt to keep safe?
*
What are the child's experiences with loss (parents, caregivers, siblings, friendships)?
*
Education/Developmental History
*
Rows
Yes
No
Comments/Explanations
Were there problems with the pregnancy or delivery of the child?
Any initial problems with eating, sleeping, or crying spells? (colic, nightmares etc)
Did the child have difficulty learning? (Give details on the child's intellectual ability)
Has the child had difficulty in school? (If Yes, be specific - for example, calculating, abstract reasoning, judgement)
Does the child have difficulty concentrating?
Does the child get along with peers?
Does the child have a normal memory, both recent and remote?
Is the child on an IEP, or in special education? (If Yes, be specific in what subjects and how this is managed at school - e.g. is the classroom behaviorally managed?)
Medical History
*
Rows
Yes
No
Comments/Explanations
Has the child seen a doctor within the last year? (If Yes, give explanation and doctors name and contact information)
Did the medical exam indicate evidence of prenatal exposure to alcohol or drugs, or other toxins?
Is the child taking any medications, prescription or over the counter?
Was the child fed an adequate amount of food? Did the feeding involve emotional closeness?
Were the physical needs met adequately? Was the child kept warm enough?
Does/has the child had any physical health conditions (including head injuries, traumatic injuries, serious illness)
Does child have any problems sleeping?
Does child have any problems eating?
Does child have any problems toileting?
Attachment, Social History and Family Functioning
Describe the child's relationship to the parents
*
Describe the child's relationship to the siblings? Please list names, ages and relationship with all siblings.
*
Describe the child's temperament regardless of the circumstances
*
Describe the chid's ability to regulate their emotions
*
What has been the parent's own experience in the regulation of their own emotions
*
What are the child's strengths?
*
What are the child's weaknesses?
*
What are the parent's strengths?
*
What are the parent's weaknesses?
*
Were there any early attachments? If Yes, please give details: When, to whom what preceded the break in attachment, the developmental stage of the child during each break of attachment
*
What is weakening attachment now that could be avoided?
*
Where is the child more open to cueing that leads to attachment?
*
Were there parting instructions that were given to the child?
*
What is the child doing that diminishes family self-esteem?
*
How is the child culturally and ethically perceived in their community?
*
What do the parents most hope for their child
*
Does the child seem to be gaining against a normal development curve, staying on the curve or maintaining a slower curve?
*
Submit Assessment
Should be Empty: