Pediatric Counseling Services

Child & Family Questionnaire (Ages 10 and under)

*Please complete this form and return it to your next appointment. This information can be valuable in providing information about your child’s history.

Person completing form: ______Date: ______

Child’s Name: ______Birth date ______Age ______

Male/Female Biological AdoptedFoster Care Other ______

Parents/Legal Guardians: ______Phone ______

Address: ______

Parents’ Marital Status: Married/Committed Single Separated/Divorce

Mother’s Occupation: ______Highest Level Education______

Father’s Occupation: ______Highest Level Education______

List all who live in household with child, age & relationship: ______

Pediatrician: ______Phone: ______Location: ______

Child referred for counseling by: ______

What would you like to accomplish with counseling services/goals?______

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Was the child adopted? Yes No If yes, at what age: ______

Pregnancy: Full TermPremature # of weeks: ______Birth Weight: ______

Vaginal DeliveryCesarean Section

Problems During Pregnancy: BleedingInjuriesMedications ______

AlcoholDrugs ______Other: ______

Did the baby experience any problems during labor/delivery or birth? If yes, please explain:

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How long was your baby in hospital after delivery: ______

Developmental Milestones (When did your child first?)

Walk alone? ______Use a single word (“up”, “ball”)? ______

Use simple sentences? ______Converse back and forth? ______

Toilet trained-Urine? ______Bowel Movements?______Night? ______

Did your child receive any Early Intervention services or outpatient developmental support services or evaluations? Please explain: ______

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Was your child been born with any physical differences or have any unusual birth marks? _____

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Does your child have any history of chronic medical issues (asthma, seizures, diabetes, etc?):

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Any recent medical concerns or testing performed through the pediatrician: ______

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Medications/Supplements: ______

Hearing or vision concerns? ______

Sleep concerns? ______

Eating Concerns? ______

Coordination/Motor development concerns: ______

Allergies: ______

History of physical/sexual abuse? ______

Unusual movements? ______

Sensory Sensitivities? (Noise, clothing, food?) ______

Previous medical testing (Ex’s Bloodwork, MRI, EEG, etc)? ______

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Recent Family Stress or Changes? ______

Please indicate if any of the following behaviors are a concern for your child:

______Paying attention______Following Directions ______Forgetfulness

______Easily Distracted______Difficulty completing tasks ______Hyperactive

______Difficulty sitting still ______Impulsive/Acting without thinking ______Argues

______Following rules______Emotionally sensitive______Often angry

______Fighting with peers______Defiant with adults______Whining

______Physically aggressive at home______Physically aggressive at school/community

______“Tunes out”/In own world______Lacks understanding of social cues

______Seems sad or unhappy______Frequent Temper Tantrums

______Withdrawn ______Feels badly about self/low self-esteem

______Difficulty separating from parent______Not interested in same age children

______Talks about hurting self______Hurts self (Explain:______)

______Does not show enjoyment in other children______Not able to share

______Can not take turns in play______Can not have a conversation

______Can not imitate action in games (clapping) ______Does not pretend play

______Does not play with toys as intended______Intense/Unusual interests

______Unusual or repetitive movements/behaviors (Explain: ______)

______Involuntary movements (blinking, twitching, etc)

______Makes noises (such as throat clearing, grunting, sniffing)

______Can not tolerate changes in routine or environment

______Bothered by touch, sound, taste, smells ______Only interacts on own terms

______Compulsive behaviors/routines (Explain: ______)

______Has many fears (Explain: ______)

______Worries excessively ______Nervous habits (picking scabs, biting nails, etc)

Family History

*Please indicate any family history for blood relatives:

Siblings / Mother’s Family / Father’s Family
Birth defects/Genetic disorders
Developmental delays
Autism/PDD/Asperger’s
Learning disabilities
Seizures/Neurological issues
Tic Disorders/Tourette’s syndrome
ADHD/ADD Hyperactivity
Depression
Anxiety or Nervousness
Bipolar Disorder/
Schizophrenia
Alcohol or Drug Abuse

Education/Intervention History

Current School: ______Grade Level ______

Current specialized services (learning support, speech, OT, PT): ______

Previous Developmental or Learning evaluations: ______

Previous Alternative Therapies: ______

Previous Psychiatric Services (Medication, Wraparound services, etc): ______

Please describe any current concerns or difficulties in the school setting: ______

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