Patient Is a Year-Old Year Old (Race):(Circle) Male Or Female

Child Assessment Form

Name:______Cell#______Date______

Patient is a ______year-old year old (Race):______(circle) male or female

Who currently resides with (list people in the home). ______

In (city and state) ______Patient is currently in the ______grade

at (name of school) ______. Patient is currently employed by______

as a(Title)______for the past (length of time)______.

PRESNTING PROBLEM:

Patient was referred by ______for problems with (please explain in detail)

______Patient is currently experiencing the following symptoms :(Circle all that apply)

Inability to pay attention / keep focus, being easily distracted, being restless and fidgety, being impulsive, being disorganized, low frustration tolerance, rapid mood swings, being easily stressed, poor self-esteem, a tendency toward addictive behaviors, family relations issues, oppositional behavior, education problems, peer conflict.

excessive and /or unrealistic worry that is difficult to control, motor tension (such as restlessness, tiredness, shakiness and muscle tension), autonomic hyperactivity (such as shortness of breath, heart palpations, nausea and or diarrhea), hypervigilance (such as feeling on edge, trouble falling or staying asleep and irritability), social phobia, separation anxiety.

depressed or low mood, suicidal thoughts and or actions, moody irritability, isolation from family or friends, lack of interest in previously enjoyable activities, low energy, low self-esteem and little or no eye contact, reduced appetite, increased sleep, poor concentration and indecision, feelings of hopelessness, worthlessness and inappropriate guilt, unresolved grief issues, mood related hallucinations or delusions.

Other

(please explain)______

Please indicate how long patient has been experiencing the above symptoms.______

BIRTH HISTORY AND DEVELOPMENT

Mother's Age at time of Pregnancy ______

Father's Age at time of Pregnancy ______

Planned Pregnancy Yes No

Known use of drugs/alcohol during pregnancy Yes No

Medical Problems/Complications during pregnancy Yes No

Prenatal Care Yes No

Full Term Pregnancy Yes No

Birth Weight ______

Complications at delivery for child Yes No

Complications at Delivery for Mother Yes No

Did baby stay more than 5 days in Hospital Yes No

Follow up Child Care Yes No

Post-Partum Depression for Mother Yes No

Follow up care for Mother Yes No

COMMENTS/Explanation of Positive Responses ______Early Development of Child:

Was growth and weight gain normal Yes No

Was there any Failure to Thrive Yes No

Was child colicky Yes No

Early Development of Child:

Age when child:

sat up independently ______

crawled ______

walked ______

spoke words ______

spoke sentences ______

Age when fully toilet trained

Any concerns about Global Development Delay Yes No

Any current enuresis or encopresis Yes No

COMMENTS/Explanation of Positive Responses______

PSYCHIATRIC SOCIAL HISTORY

Were you adopted? Yes No

Did your biological parents separate or divorce during your childhood? Yes No

Loss of parent by death prior to age 18 Yes No

Would you consider your childhood happy average unhappy

Was upbringing (economic class ) lower middle upper

During childhood, were you ever concerned about any form of

Emotional abuse Yes No

Physical abuse Yes No

Sexual abuse Yes No

Education

Current Grade:______Highest grade completed______

College Degree______Graduate Degree______

Special Education

Does child have IEP Yes No

Does child have 504 Plan Yes No

GED earned ______

Vocational/Trade School ______

Current Occupation: ______

Social

Peer Relationships:

Nature of child's relationship with peers in various settings ______

Community/Cultural Involvement: ______

Does family participate in community activities Yes No

Does the child usually attend religious services Yes No

Is the child involved in community activities Yes No

COMMENTS/Explanation of Positive Responses ______

Methods of Discipline and Effectiveness: ______

Has child been subjected to neglect or physical abuse Yes No

Has child been subject to sexual abuse Yes No

Has child ever been assaulted in the community Yes No

Has child ever witnessed violence or been involved in violent episode Yes No

Relationship leave blank if not applicable

Current Relationship Status:______

Have you ever been divorced? Yes No

Current relationship is poor fair good

Are you currently sexually active? Yes No

Sexual Preferences? Opposite sex Same sex Bisexual

Do you have any concerns or difficulties with sexual functioning? Yes No

Are you pregnant? Yes No Not applicable

Are you trying to get pregnant? Yes No Not applicable

Number of children: ______

Spirituality: none non-practicing active ______

Legal History

Is custody of child with biological family Yes No

Is child adjudicated dependent Yes No

Past C&Y involvement or services Yes No

Any past Foster Care placement Yes No

Juvenile Justice:

Has the child ever been arrested Yes No

Is the child adjudicated delinquent Yes No

Any past placement in Detention Yes No

Any past placement in a YDC Yes No

COMMENTS/Explanation of Positive Responses______

PAST PSYCHIATRIC HISTORY

Prior outpatient psychiatric treatment in the past? Yes No when/where______

Prior outpatient alcohol/substance abuse treatment? Yes No

Prior outpatient treatment was helpful? Yes No

Number of prior psychiatric hospitalizations:______

Date of last psychiatric hospitalization: ______

Number of prior alcohol or substance abuse hospitalizations: ______

Date of last alcohol/substance abuse treatment: ______

Involuntary hospitalizations in past? Yes No

Other levels of Care ______

Prior History of non-suicidal injury (scratching, cutting, burning)? Yes No

Prior History of suicide attempt? Yes No

Number of attempts ______

Date of last attempt was: ______

Method of self-harm: ______

Attempt resulting in medical hospitalization: Yes No

Prior History of Aggression or Violence? Yes No

Aggression towards: ______

Legal charges stemming from aggression: Yes No

Incarceration stemming from aggression: Yes No

Prior Psychiatric medications tried: ______

SUBSTANCE USE HISTORY Leave Blank if not applicable

Alcohol: (beer, wine, liquor) Yes No