Form 2A
PAULA P. MERUCCI, LLC
LCSW, CADC
2530 Crawford Avenue, Suite 115
Evanston, IL 60201
Child and Adolescent / Client Information Form
Client Name:______
In order to most efficiently use your face-to-face time with your therapist, please complete this form. This information will enable your therapist to better understand you and help you. If there are any questions you do not wish to answer, please draw a line through them, and initial the item(s).
Name of client: ______Sex: _____ DOB: ______Provider: ______
Evaluation date: ______Form filled out by: ______
Referred by: ______Persons present for evaluation: ______
Briefly describe the events that led to this appointment:
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What concerns you most about your child? ______
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What are your goals for the evaluation?
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Have you seen other professional about these problems? If yes, list these contacts and approximate dates of evaluation and treatment (include hospitalization dates).
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Please list past and current medications and approximate doses and dates of treatment.
Medication(s)Doses Dates of Treatment
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Section 1 - Developmental History
Pregnancy/neonatal/infancy:
Were there any complications with the pregnancy or your child’s delivery (i.e. medications, prematurity, fetal distress, low Apgars, C-section)? Were there any medical problems in the first two years of life?
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Developmental milestones and concerns:
Did/does your child have problems with the following developmental milestones?
Please note the dates you had concerns about the problem.
Feeding concerns?______Breast Fed? How long? ______Physical growth problems? ______Colic? ______Sleep habits? ______Sleep through the night? ______Sleeping alone? ______Age of walking? ______Clumsiness? ______
Age of first words, first sentence?______
Other language concerns? ______Age of bowel training? Current soiling? ______
Age of bladder training? Current wetting?______
Hygiene concerns? ______
Problems separating from parents?______
Past and current peer relations? ______
What do you see as your child’s strengths and weaknesses? ______
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Section 2- School History
What is your child’s grade and school? ______
What other schools has he/she attended? ______
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Has your child been in special education? Have there been learning problems?
Please give details of problems and supports.
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Do you have concerns about the school problem?______
Has there been psychological testing? When? Results? Please bring documents to the evaluation, if available.
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What is your child’s attitude toward school? ______
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What are your hopes for your child’s educational attainment and vocational future? ______
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Section 3 - Social History
List the names, ages, and occupations/grades of family members in the current household.
NameAgeGrade/Occupation
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List immediate relatives (biological or relatives by marriage, parents, or siblings) or other primary caretakers (sitters, day care) of the child outside the primary home. Has there been any significant history of problems with caretakers, such as abuse or neglect? ______
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Are there any particular stressors or recent changes in the family such as job changes, financial problems, school changes, health problems, marriage or divorce, violence, or substance abuse? ______
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Who is responsible for disciplining? What methods work or haven’t worked? Do caregivers/parents agree on discipline? ______
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How well does your child get along:
With siblings?______
With peers?______
With parents? ______
By himself/herself? ______
What are family activities or mealtimes like? Does your child have other activities or hobbies?
Favorite TV or movies? ______
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Section 4 - Medical History
Child’s local physician: ______
Address: ______
Phone: ______
Date of last physical exam: ______
Has your child seen a specialist, such as neurologist, etc? Please list names, approximate dates, and reasons for consultation. ______
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Allergies (environmental, food, and/or medication relates): ______
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Current medicines, or any medicine ever taken over 6 months duration (include over the counter or “natural” medicines):
Medication(s)Doses Dates of Treatment
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Medical concerns (give details if applicable):
□ Asthma or breathing problems______
□ Headaches______
□ Gastrointestinal concerns______
□ Head injury history______
□ Seizures______
□ Ear infections ______
□ Frequent or recent strep infection______
□ Heart murmur or problems ______
□ Hospitalizations or surgeries______
□ Hearing loss (testing done?) ______
□ Vision problems______
□ Onset of puberty or menses______
□ Sexual activity______
□ Other medical concerns______
Section 5 - Family History
Please identify if there is a history of the following problems in the child’s genetic or natural family, and indicate briefly the problem and relative (for example, seizures in a maternal aunt):
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Alcohol and/or drug problems in family members: ______
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Eating problems in family members?______
ADHD or school behavior problems in family members: ______
Conduct problems or court involvement in family members: ______
Mental retardation, learning, disabilities, or other developmental problems: ______
Mood problems (suicide, depression, or manic-depressive illness) treated or untreated in family members:___
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Anxiety and panic problems in family members: ______
Schizophrenia in family members: ______
Neurologic problems such as seizures, or migraines: ______
Tics or Tourette disorder: ______
Thyroid problems in family members: ______
Genetic syndromes in family members: ______
Cardiac or other medical problems in family members: ______
PLEASE NOTATE AND COMMENT AS APPROPRIATE:
□ careless/poor attention to details ______
□ difficulty sustaining attention ______
□ doesn’t listen______
□ doesn’t follow through with requests______
□ difficulty organizing______
□ avoids effortful tasks______
□ loses necessary things______
□ easily distracted______
□ forgetful in daily activities______
□ fidgets______
□ leaves seat ______
□ runs about/subjectively restless ______
□ difficulty playing quietly______
□ “On the go” / “motor driven” ______
□ excessive talk ______
□ blurts out answers______
□ difficulty waiting turn ______
□ interrupts/ intrudes______
Where are these problems present? In the home, in the school, or other settings? Comments: ______
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PLEASE NOTATE AND COMMENT AS APPROPRIATE:
Stealing in the home or out of home?______
Lying ?______
Truancy/runaway?______
Violence in the family?______
Violence at school?______
Violence in the community?______
Fire setting or fire play?______
Cruelty to animals?______
Legal involvement with juvenile services?______
Inappropriate sexual interests and behavior?______
Lack of conscience?______
Threats of violence ?______
Exceptional negativity to rules?______
Comments:______
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Alcohol use?______
Cigarette use?______
Marijuana use? ______
Other substance use?______
Comments:______
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Expresses depression or hopelessness or low self esteem?
Comments:______
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Can be irritable or giddy or elated inappropriately? ______
Hypersexual or loss of other inhibitions? ______
Mood swings (circle period of change MINUTES, HOURS, DAYS, WEEKS, or MONTHS)______
Moods change without reason? ______
Lack of interest in friends or normal activities? ______
Poor sleep or excessive sleep?______
Poor eating or excessive eating or concerns over weight changes or dieting ?______
Binging with or without purging (self induced vomiting)? ______
Suicidal talk or acts of self-harm or mutilation?______
Comments:______
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School refusal or excessive absences?______
Anxiety at bedtime or in the night / refusal to sleep alone ?______
Fears of harm to family members? ______
Complaints of physical symptoms such as headache or stomach ache?______
Specific phobias (heights, spiders. etc.)?______
Sudden feelings of panic? ______
Refusal to speak in public, or refusal to go out in public ?______
History of trauma (abuse, accident, etc.) ?______
Nail biting, thumb sucking, teeth grinding, hair pulling, skin picking? ______
Over concern regarding germs, illnesses, contamination by dirt, or other obsessive thoughts? ______
Overly perfectionist ?______
Comments:______
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Tics or twitches of the mouth, eyes, facial muscles, or arms and legs?______
Head banging or rocking?______
Other repetitive movements such as jumping or arm/hand flapping or spinning?______
Lack of affection (doesn’t seek out or provide comfort)?______
Little need for reassurance in a strange situation, or little stranger anxiety?______
Poor peer relations / no real friends?______
Problems understanding feelings of others during interactions?______
Distress over change in routine?______
Unusual toy or play interests (collections, string, line up or take apart toys rather than play)?______
Restricted conversational interests (dinosaurs or specific topics to the exclusion of other topics)?______
Hoarding food or other objects?______
Comments:______
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Odd thinking or peculiar ideas?______
Difficulty discerning what is real vs. normal fantasy play?______
Paranoid thinking?______
Hearing voices?______
Seeing things not there?______
Periods of odd sensations or loss of memory for a period of time?______
PLEASE ADD COMMENTS IF YOU HAVE ANY OTHER CONCERNS NOT ALREADY NOTED
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