Parent/ Legal Guardian’s Full Name: First Name Last Name Parent/ Legal Guardian’s Telephone Number: Area Code Phone Number Child’s Full Name: First Name Last Name Child’s Date of Birth: Date
Has your child ever received psychological/ psychiatric help before? If yes:a) What was the diagnosis?Type a label b) What kind of treatment did they receive?Type a label c) When did they receive the treatment, and where?Type a label d) When did the treatment end? Type a label Was your child ever prescribed psychiatric medications? If yes:a) Which medication was the child prescribed? What was the dosage?Type a label b) How long was the medication used?Type a label c) Did the child experience side effects? What were the side effects?Type a label
What was your child’s birth weight?Numberlbs. Numberoz. OR Unknown Was delivery normal?Yes Unknown No (specify) Specify Did the birth mother consume alcoholic beverages or abuse any street drugs during pregnancy?No Unknown Yes (specify) Specify Did the baby experience any problems immediately after birth?No Unknown Yes (specify) Specify Did caregivers feel bonded to the child throughout infancy?Yes No (specify) Specify Is there any history of physical, sexual, or emotional abuse?No Unknown Yes (specify) Specify Any disruptions in the child’s caregiving relationships?No Yes (specify) Specify How would you describe your child’s approach to new situations?Positive, jumps right in Withdrawn Slow to warm up, cautious Has your child ever failed a class or been held back for academic reasons?No Yes Specify
Fighting Disagreeing about friends Disagreeing about relatives Feeling distant Loss of fun Alcohol or Drug use Trauma Lack of honesty Medical Concerns Education problems Infidelity (couple) Divorce/separation Issues regarding remarriage Financial problems Death of a family member Inadequate health insurance Birth of a child Job change Inadequate housing
Do you currently use alcohol? Yes No If yes, how often do you drink? Daily Weekly Occasionally RarelyDaily Weekly Occasionally Rarely If yes, how much do you drink?Number (#) per time.Do you currently use Tobacco?Yes No If yes, how much do you smoke/chew? Do you currently use any other drugs?Yes No If yes, what drugs do you use? If yes, how often do you use?Daily Weekly Occasionally Rarely Have you received any previous treatment for chemical use? Yes or No? If so, where did you go? Inpatient or Outpatient?Inpatient Outpatient Have you ever used more than 1 chemical at the same time to get high? Do you avoid family activities so you can use? Do you have a group of friends who also use? Do you use to improve your emotions such as when you feel sad or depressed?