History and Background p. 2

History and Background Information

Child’s name: Date of birth Today’s date:

Parent/Guardian Name:

Address:

Home & work phone:

Name of person filling out this form and your relationship to child (if different from above):

Please note that these questions are only a guide. Feel free to use additional sheets for any questions, and skip or expand on any question you wish. If you prefer not to use the form you may simply use it as a guide to the kind of questions I will be trying to answer in the first stage of my evaluation.

  1. What led you to seek psychiatric evaluation for the child?
  1. How long has this problem been going on?
  1. Please describe any problems this child is having at home:
  2. Behavior Problems
  3. Emotional Problems
  1. Please describe any problems this child is having at school:
  2. Behavior Problems/Problems with Authority
  3. Emotional Problems
  4. Academic Problems/Problems with learning
  5. Social Problems
  1. Please describe any problems this child is having in the community (outside home and school), including legal and conduct problems:
  1. Other concerns:
  1. Does this child display unusual moodiness or defiance?
  2. Odd thoughts or preoccupations?
  3. Any wishes/threats/acts to hurt him or herself?
  4. Unusual rituals (e.g. counting, touching, repeating actions, turning lights on and off)?
  5. Indications of drug or alcohol abuse?
  6. Developmental history
  7. Planned pregnancy? Prenatal drug/alchohol/medication exposure? Unusual stresses or family problems during pregnancy? Problems during delivery? Happy, healthy newborn? Irritability problems? Sleep or feeding problems? Serious illnesses or injuries in infancy?
  8. At what age did this child Talk (single words) (sentences) Walk:
  9. Speech/language/sensory problems?
  10. Problems with bowel or bladder control (include age)?
  11. At what age did this child begin daycare/nursery school?
  12. Separation or socialization problems?
  13. Phobias?
  14. What was this child’s play like as a young and older child?
  15. Did he or she play comfortably alone?
  16. Did he or she play with others?
  17. Comfortable with team sports and structured group activities?

Please provide any additional comments here:

  1. Past psychiatric history: please describe any contact this child had with previous mental health caregivers, including (if possible) the name of the caregiver, date of intervention, reasons for intervention, duration of intervention, and outcome:
  2. Medication History. If this child has received psychotropic medication in the past, please list the medication, date of treatment, who prescribed it, what the indication for the medication was, whether the medication helped, presence of any side-effects, and duration of the treatment. (If you can’t provide all these details, simply provide as much information as you can)
  3. Medical History. Please describe any serious medical problems, medical hospitalizations, medication allergies. Is the child receiving any non-psychotropic medications or medical treatment?
  4. Contact with pediatrician and prior caregivers: Please fill out the attached information.


Release to pediatrician

Name of child: Date of Birth:

Name of pediatrician:

Address:

Phone # Fax # (if known):

I give permission to the above-named physician to communicate with each other about the above-named child, in order to enhance this child’s medical care. Unless otherwise specified, this may include release of medical history, physical examination, laboratory reports and medication records to Dr. Lerman, and updates by Dr. Lerman to the treating pediatrician about medication or other relevant treatment records.

Signature and date

Release to prior/current mental health caregiver:

Name of child: Date of Birth:

Name of caregiver:

Address:

Phone # Fax # (if known):

I give permission to the above-named clinician to communicate with each other about the above-named child, in order to enhance this child’s medical care. Unless otherwise specified, this may include release of evaluation, treatment, psychological testing and/or medication records to Dr. Lerman.

Signature and date

(if more than one caregiver, please write out permission on a separate page.

Release to school personnel:

Name of child: Date of Birth:

Name (s) of school staff:

School:

Address:

Phone # Fax # (if known):

I give permission to the above-named clinician to communicate with each other about the above-named child, in order to enhance this child’s medical care. Unless otherwise specified, this may include release of evaluation, treatment, psychological testing and/or medication records to Dr. Lerman. Dr. Lerman will exercise discretion sharing personal information with school officials.

Signature and date

This document is a confidential patient record protected under all applicable privacy statutes