DFS Child Client Information Form
Please be sure to fill out the entire form and press the "Submit" button at the end
Today’s date
/
Month
/
Day
Year
Date
Child’s Name
First Name
Middle Initial
Last Name
Child’s Date of Birth
/
Month
/
Day
Year
Date
Gender
Parent/Legal Guardian's Name
First Name
Middle Initial
Last Name
Home street address
City
State
Zip
Home Phone
Child Cell
Parent Cell
Parent work phone
Parent email
example@example.com
Child email
example@example.com
Please indicate any restrictions for phone or email contact
Parent or Legal Guardian’s Name of Employer
Address of Employer
City
State
Zip
Sexual Orientation
Heterosexual
LGBTQIA
Prefer not to say
Ethnicity
Caucasian
African
American Latino/a
Asian/Pacific
Islander
Bi/multiracial
Other
Referred by
May I have your permission to thank this person for the referral?
Yes
No
If referred by another clinician, would you like for us to communicate with one another?
Person(s) to notify in case of emergency
Phone
Back
Next
Medical / Developmental History
Has your child had any significant developmental or medical problems?
Yes
No
Please explain significant developmental or medical problems, symptoms, or illnesses
Current Medications:
Rows
Name of Medication
Dosage
Purpose
Name of Prescribing Doctor
1
2
3
4
5
Previous medical hospitalizations (approximate dates and reasons)
Previous psychiatric hospitalizations (approximate dates and reasons)
Has your child ever talked with a psychiatrist, psychologist, or other mental health professional? (If yes, please list approximate dates and reasons)
What are your child’s diet, weight, and exercise/activity patterns?
What are your child’s diet, weight, and exercise/activity patterns?
Does your child/adolescent smoke cigarettes?
Yes
No
Does your child/adolescent vape?
Yes
No
Does your child/adolescent use drugs recreationally?
Yes
No
Which drugs?
Has child/adolescent had legal or school problems related to above usages?
Yes
No
What kind of problems?
Comments about child/adolescent substance use
Back
Next
Current Presenting Concerns
Please briefly describe your child’s presenting concerns (why you are bringing your child to therapy):
What are your/your child’s goals for therapy?
At what age did you first notice that your child had any emotional and/or behavioral difficulties?
0-12 months
1-2 years
3-5 years
6-12 years
13 or older
Problem/Symptom
Rows
Never
Rarely
Sometimes
Frequently
Most of the Time
Seems unhappy
Withdrawn
Irritable/Angry mod
Gets very upset when something doesn't work out
Suicidal thoughts/behavior
Often anxious, fearful, worries
Obsessive or compulsive behavior
Separation anxiety
Lack of self confidence
Difficulty with change
Difficulty making and keeping friends
Socially awkward
Bullies other children
Assumes others won't like them
Speech/language problems
Learning problems
Poor grades
Trouble completing assignments
Trouble focusing on schoolwork
Doesn't listen to teachers
Hyperactive behavior
Highly distractible
Substance use
Self-harm
Lying/cheating with parents/authority figures
Fights with siblings
Poor grades
Conflict with parents
Performs repetitive rituals/movements/ gestures/speech (like rocking, spinning, or hand flapping)
Obsessive interests
Poor eye contact
Prefers being or playing alone
Speaks with abnormal tone or rhythm (like a singsong voice or robot-like speech)
Overeating or obesity
Other:
What are your child's main strengths?
At home
At school
Other
What are your child’s hobbies and talents?
Please describe your child's.....
Rows
Poor
Below Average
Average
Above Average
Excellent
Level of happiness
Ability to feel good about self
Ability to turn to relationships when something goes wrong
Ability to seek attention in positive and pleasurable ways
Back
Next
Family
Child's Parents are:
Married
Divorced
Separated
Never Married
Deceased
Other
Deceased (specify)
If parent(s) are divorced or deceased, how old was the child and how do you think this impacted them?
How would you describe your relationship with your mother?
How would you describe your relationship with your father?
How would you describe your relationship with stepparents, if applicable?
Please describe your child’s relationship with their grandparents
Were there any other primary care givers who have had a significant relationship with your child? If so, please describe how these people may have impacted your child’s life
Child lives with
Others that live in the household include
How many sisters does your child have?
Ages?
How many step/half-sisters does your child have?
Ages?
How many brothers does your child have?
Ages?
How many step/half-brothers does your child have?
Ages?
How would you describe your child’s relationship with their siblings?
Back
Next
Peer Relationships
Please describe your child's ability to.....
Rows
Poor
Below Average
Average
Above Average
Excellent
Initiate interaction with peers
Develop and maintain friendships
Enjoy friendships
Appear satisfied with social life
Get along with peers
Overall, my child's social/peer relationships are...
Comments/concerns about peer relationships
School Functioning
School
Grade
Please describe child's.....
Rows
Poor
Below Average
Average
Above Average
Excellent
Grades
Enjoyment of learning
Study/homework habits
Ability to attend/focus
Ability to follow classroom rules
Overall in school, my child is doing
Comments/concerns about school/academic functioning
Back
Next
Stressful Life Events
Traumatic/Stressful Experience
Rows
Has this EVER happened?
Has this happened within the last year?
Separation / Divorce of parents
Remarriage of parents
Birth of siblings
Physical abuse of child client
Sexual abuse of child client
Child witnessed domestic violence
Child witnessed physical conflict between family members
Child witnessed violence in the community
Bullied in school or community
Experienced significant medical illness
Child has special needs
Medical illness of parent
Death of parent
Death of close family member
Family financial problems
Loss of employment for parent(s)
Marital / Couple conflict
Family conflict
Foster care
Adoption
Care in an orphanage
Multiple moves
Depression or anxiety in parent(s)
Substance abuse in parent(s)
Parent has significant mental illness
Family member had legal problems related to interaction with legal system / crime
Other (please indicate below)
Briefly describe any history of abuse, neglect, and/or trauma
Submit
Should be Empty: