Clinical Assessment (Child)

Clinical Assessment (Child)

Identifying Information

Legal Name: ______Goes by: ______

DOB: ____/____/______Age: _____ School: ______Grade: ______Teacher: ______

Legal Guardian: ______Relationship: ______

Address: ______City/State: ______Phone: ______

Family Statistics

Child Lives with: ___ Both Parent(s) ____parent(specify) ______other (specify)

Language Spoken in the home: _____English ____ Spanish______other (specify)

Parents Marital Status: ___ Single _____Married ______Divorced______Widowed_____ Remarried______Separated ______

Father: ______Mother: ______

Address: ______Address______:

Phone: ______Phone: ______

Birthplace: ______Birthplace: ______

Employer: ______Employer: ______

Occupation: ______Hours: ______Occupation: ______Hours: ______

Age: ____ Health: ______Age: _____ Health: ______

Highest Grade Completed: ______Highest Grade Completed: ______

Other Significant Adults: Step Parent ______foster ____ relative caretaker______Other: ______

Numbers of years with the family: ______

Name:______Name :______

Address: ______Address______:

Phone: ______Phone: ______

Birthplace: ______Birthplace: ______

Employer: ______Employer: ______

Occupation: ______Hours: ______Occupation: ______Hours: ______

Age: ____ Health: ______Age: _____ Health: ______

Highest Grade Completed: ______Highest Grade Completed: ______

Siblings / Relationship / Age / In/Out Home / School/Grade/Occupation
Others in the Home:

======Do Not Write Below Line======

Reason for Seeking Treatment:

1.  Parent(s)/Guardian(s) Perception of Issue/ Problem and Development:

First Aware: ______

______
______
______

______

______

______

Efforts made to resolve problem: ______

______
______
______

School History

Grade (s) School/Location Special Services Reason(s)/Comments

Does the child require additional assistance with school work? YES/NO

Doe the child attend school regularly? YES/NO

Does the child appear motivated to go to school? YES/ NO

Has the child ever been suspended or expelled? YES/ NO

Has the child ever had special testing in school? YES/ NO

If yes, please explain ______

______

Highest grade on report card? ______

Lowest grade? ______

Favorite Subject? ______Least favorite?______

Does the child participate in any extracurricular activities? YES/NO

List: ______In school, how many friends does the child have? A LOT/ FEW/ NONE

Who are the child ‘s friends? ______

______

List special interests, hobbies, and skills: ______

______

======Do Not Write Below Line======

Development and Health History

Prenatal

Unusual health problems/diseases prior to pregnancy? ______

Complications or illnesses during pregnancy: ______

Age of mother at birth______Number of this pregnancy______

Mother’s emotional state during pregnancy: ______

Was the conception planned? ______

Comparison to this pregnancy to others? ______

Onset of prenatal care______Doctor/Hospital______

Medications taken during pregnancy? ______

Use of drugs, alcohol, tobacco______

Delivery

Length of Pregnancy ______Child’s condition at Birth______Birth Weight______

Any known injuries? ______

Special Medical Attention or Hospitalization required during first month______

Early Development (give ages in months)

Personality of Baby? ______

Sat alone______Crawled alone______Stood alone______Walked alone____ Talked alone______First word______

First sentences______

Any articulation / speech problems? ______

Any developmental delays to be aware of? ______
Began toilet training______Completed Toilet Training______

Dry day and night______Returned to wetting/soiling at any time______

Chronic and/or Current Problems (check and explain if necessary)

____ frequent colds ____ fevers ____ unusual sleeping patterns Comments: ______

____ earaches ____ aches & pains (talking in sleep, sleepwalking,

____headaches ____ head banging naps, excessive sleep, decrease sleep) ______

____ constipation ____ rocking ____ unusual eating patterns ______

____ asthma ____ crying spells ( food patterns, poor/excessive) ______

____ allergies ____ temper outbursts ____ ritualistic behaviors ( compulsive) ______

____ diarrhea ___ difficulty attending ____sibling rivalry ______

____ sinus ____ fears ____ daydreaming ______

____ suicide thoughts ------morbid thoughts ____ irritability

------suicide attempts _____ mood swings ____ decrease in energy/interests

____ thoughts of _____ anxiety ____ hurts self ( cuts, burns, scratches)

harming others

Current medications and dosage: ______

Current health state______

Are there any medical factors contributing to the child’s academic, behavioral, or social emotional functioning? YES/NO

If yes, please explain: ______

======Please Do Not Write Below Line======

Family Health History: (relationship and Illness)

______

______

Family History:

Identify significant changes which may have affected the child? Please put months and years as well as age of child for each change. (i.e. serious illness, hospitalization, death of a member family/friend/pet, change of residence, divorce, separation, parental absences, abuse (physical, emotional, sexual), abandonment, neglect, financial stress) ______

______

______

______

______

Describe child’s relationship and activities with father: ______

______

______

Describe child’s relationship and activities with mother: ______

______

______

Describe child’s relationship with siblings:______

How would siblings describe child?______

Who does the child appear to be most like in the family? How? ______

______

Identify family social experiences (e.g. clubs, travel, pets, religion, etc.) ______

______

Peer Relationships

(socialization/attitudes, - cooperation, consideration, awareness of others, group participation, sharing, selfishness, social maturity, familiarity with strangers)

Describe the child’s relationship with neighborhood children______

______
______

Has the child been involved in any organized activity? (Park District, Scouts, Church, School Clubs, Etc.) ______

______

How does your child spend his / her free time? (how much TV, games, hobbies, special interests) ______

______

______

======Do Not Write Below Line======

Parent’s description of Child’s Behavior/ Adaptive Behavior?

Describe child’s daily routine? ______

______

______

What chores or responsibilities do you expect of your child? ______

______

When is discipline necessary? Who does it? How? ______

______

______

Describe any police intervention, arrests, convictions, probations______

______

Describe child’s personal hygiene habits?______

Describe child’s eating habits? (food, restaurant/home) ______

______

Describe child’s bedtime and sleep habits______

______

Describe child’s use of money/ allowance/ bugeting______

______

Describe your child’s strengths (academically, personality, etc) ______

______

Spiritual/ Religious/ Cultural Background

What faith/religion does the child and or family follow or believe in?______

______

How often does the child and / or family attend religious services? ______

______

Are there any religious or cultural issues that might impact treatment? ______

If yes, please explain: ______

First and Last Name of Individual Completing this: ______

Print First and Last Name

Relationship to Child: ______

______

Signature date

======Do Not Write Below Line======

3