Let's "hit the ground running."

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Help us to know a little about your child and your family, and what brought them to our office. It's important that you be as honest as you feel comfortable being and take the time to answer every question as thoroughly as possible. By answering these questions you’ll insure that we don’t waste the first few sessions covering “the basics.”
You’ll also feel better understood, and it will help us make the most of my time with your child.

Email *

Child's First & Last Name: *

Your First & Last Name: *

Your relationship to this Child *

Child's Date of Birth *

YYYY

Grade Level & Name of School Attended

Please describe what prompted you to make this appointment:

What would you like to come out of us working together?

What is your best guess of how long it should take to accomplish this?

1-3 Sessions

4-12 Sessions

13-20 Sessions

I have no freaking clue.

Clear selection

Imagine we're a few sessions into your treatment: What's the first thing that you will notice that will let you know that things are getting better?

What have you tried thus far to address this problem?

What do you think is stopping you (or has stopped you) from successfully addressing this problem?

Health Questions

The following questions refer to your child's Health and Development. It may be hard to remember some of the following information, especially if your child is now a teenager. All of the information is very important, so please try to answer as completely as you can.

Were there any complications with the biological mother's pregnancy?

Yes

I don't have that information.

Clear selection

If you answered, "Yes," please explain.

Mother's health during pregnancy (describe any illnesses or complications):

Were there any complications during the delivery? If so, please explain:

Was the child premature?

Yes

Clear selection

If you answered, "Yes," please explain:

Height and Weight at Birth: (inches and pounds)

Was your child doing the following things by the ages listed below?

5-8 mos.

7-9 mos.

10-14 mos.

11-14 mos.

11-15 mos.

20-25 mos.

At or Before 2 yrs. 3mos.

At or Before 3 yrs. 3 mos.

At or Before 4 yrs.

At or Before 6 yrs.

Sat up without support

Made 2-syllable word sounds (ma-ma, da-da)

Stood without holding onto something

Said First *full* word

Walked

Said 2 word sentences ("go home" "want that")

Fed self with a fork/spoon

Helped when being dressed

Was Toilet Trained

Dressed themselves

5-8 mos.

7-9 mos.

10-14 mos.

11-14 mos.

11-15 mos.

20-25 mos.

At or Before 2 yrs. 3mos.

At or Before 3 yrs. 3 mos.

At or Before 4 yrs.

At or Before 6 yrs.

Sat up without support

Made 2-syllable word sounds (ma-ma, da-da)

Stood without holding onto something

Said First *full* word

Walked

Said 2 word sentences ("go home" "want that")

Fed self with a fork/spoon

Helped when being dressed

Was Toilet Trained

Dressed themselves

Does your child have a best friend?

Yes

If yes, what is the age of the best friend?

In general, how does your child get along with peers that are:

Very Poor

Poor

Well

Very Well

The same age

Younger children

Older children

Adults

Consider your child's life from birth to now, which of the following have they had in the past or are you dealing with currently? (Check ALL that apply)

Infant/Toddler (0-4 yrs)

Early Childhood (5-10 yrs)

Pre-teen / Adolescence (11-17 yrs)

Young Adult (18-21)

Illness/Disease

Accidents

Injuries

Surgeries

Hospitalizations

Loss of Consciousness

Convulsions/Seizures

Medical Conditions

Please provide details of the above conditions. I'm interested in knowing: What was the diagnosis? How old were they when it started? Was it treated, and by whom? What was the result (treated? resolved? ongoing?)

Please list any medications your child is currently taking, the condition they are taking them for, when they began taking them (or how long), and who prescribed them.

Please list any over the counter supplements or treatments they are currently taking, why they are taking them, and how long they have been taking them.

Please list your child's current family doctor or pediatrician, their location, and their phone number. If there are specialists involved, please list their info as well.

May we contact your current physician for the purposes of treatment planning?

Yes

Clear selection

If you are being seen by any Specialists (oncologist, psychiatrist, physical therapist, etc.) please list their names, phone numbers, and the conditions they are treating you for.

How many hours of sleep does your child usually get per day?

Any difficulty falling or staying asleep?

Yes

Clear selection

Do they usually feel or seem rested when they awake?

Yes

Clear selection

How is your child's energy level?

Too High

High

Seems Normal

Low

Too Low

Clear selection

How is your child's appetite?

Too High

High

Seems Normal

Low

Too Low

Clear selection

Has there been a recent change in your child's appetite?

Increase

Decrease

No Change

Clear selection

How much / what does your child typically eat?

Mental Health

The following questions refer to your child's Mental Health.

Please list any prior mental health treatment or psychological testing conducted that have not already been mentioned in the Health section of this form:

Check all that apply to your child.

(select all that apply)

Depressed

Overweight

Shallow

Weak

Helpless

Hopeful

Tough-Skinned

Bizarre

Self-critical

Anxious

Shy

Outgoing

Distant

Lost

Poor Memory

Caring

Grieving

Jolly

Friendly

Procrastinating

Underweight

Low Self-Esteem

Hopeless

Poor Concentration

Secretive

Empty

Forgiving

Confused

Helpful

Inept

Sarcastic

Short-fuse

Hyper-active

Passive

Sad

Nervous

Irritable

Precise

Proud

Self-doubting

Dependable

Guilty

Overwhelmed

Clear selection

Has your child been the victim of or witnessed (in the past or currently):

Yes

Domestic Spousal Abuse / Violence

Physical Abuse

Emotional Abuse

Sexual Abuse or Assault

Clear selection

If the answer to any of the above questions about abuse is "yes," was the abuse reported?

Yes

Clear selection

If it was reported, what was the outcome?

Is the abuse still going on?

Yes

Clear selection

Has your child ever discussed or attempted suicide?

Yes

Clear selection

If "yes," please describe:

Is there a family history of mental health concerns or treatment?

yes

Clear selection

If "yes," please describe:

Please list all schools that your child has attended, starting with current or most recent:

In general, how does (or how did) your child do in the following areas in school:

Very Poor

Poor

Well

Very Well

Adjustment to school?

Academics?

Peers?

Teachers, Principals, or Professors?

Extra Curricular Involvement?

Clear selection

School Disciplinary History: Please list the dates, type of action, who the action was taken by, and the outcome of any disciplinary actions taken:

Is there anything else you'd like me to know about your child's current school situation that wasn't covered above?

Some Demographics & History:

A few questions about your life situation and education.

Current Family Income (annually):

Below $10,000

$10,000-25,000

$25,001-50,000

$50,001-75,000

$75,001-100,000

$100,001-$150,000

Above $150,000

Clear selection

Your Child's Family Members (Check ALL that apply)

Alive

Deceased

Get Along Well

Get Along Poorly

Estranged

Does not know

Father

Mother

Stepfather

Stepmother

Foster Father

Foster Mother

Sibling

Sibling 2

Sibling 3

Sibling 4

Sibling 5

Sibling 6

Other Family Members

Father's Age, Occupation and Education

Mother's Age, Occupation and Education

Stepfather's Age, Occupation and Education

Stepmother's Age, Occupation and Education

Please list *all* individuals who currently live with your child. Include any information about foster home placement, or custody arrangements for separated/divorced parents.

Lifestyle

For the parent or guardian: Marital / Relationship History. Please include information regarding significant romantic relationships in your life.

Marital & Relationship History: Please indicate your current relationship status:

Single

Married

Divorced

Widowed

Estranged

Separated Amicably

Clear selection

If you are in a relationship: How did you meet your Current Spouse/Partner? How long have you been together?

Describe your current relationship:

Positive things about your Current Spouse/Partner:

Negative things about your Current Spouse/Partner:

Previous Spouse/Partner: When did you get together/get married, and how long were you together?

Describe your Previous Relationship:

Positive things about your Previous Spouse/Partner:

Negative things about your Previous Spouse/Partner:

If you are Divorced, what let up to the divorce?

Other Children

A few questions about your other children, if you have them.

Do you have other Children?

Yes

Clear selection

Please check all that apply:

6 or more

Biological Children

Step-Children

Adopted Children

Foster Children

Deceased Children

Clear selection

Please list your other Children's Names, Dates of Birth, & Ages *who live in the same home as the child you are filling out this form for*:

For the children listed above who live with you: Please list the School Attended Currently, Grade, and any Difficulties or Problems they are experiencing.

Please list any other Children's Names, Dates of Birth, & Ages *who do not currently live in your home*:

For the children listed above who *do not* live with you: Please list the School Attended Currently, Grade, and any Difficulties or Problems they are experiencing.

Legal History

Please list any situations that have brought you in contact with the legal system, law enforcement, or the courts. Please list the date or your approximate age, describe the situation, and describe the outcome:

Lifestyle choices.

This section refers to use of substances that are NOT prescribed by Doctors or are used recreationally.

The following questions concern only your Child's use of alcohol and drugs. You will receive a separate form to fill out for yourself and other family members if necessary.

As a Child

As a Teen

Currently Use / Used Recently

Past - they decided to stop

Past - their parents/guardians stopped them

Past - Court / Law Enforcement Involvement

Caffeine

Nicotine

Alcohol

Amphetamine (Speed, Uppers)

Depressants (Xanax, Klonopin)

Inhalants (Whip-its, Paint, Glue)

Marijuana (Pot, Weed, Dabs, Edibles)

Narcotics (Vicodin, OxyContin, Percocet, Heroin)

Cocaine (blow, crack)

Methamphetamine (meth, crank, ice, glass, crystal)

Ecstasy (Molly, MDMA)

As a Child

As a Teen

Currently Use / Used Recently

Past - they decided to stop

Past - their parents/guardians stopped them

Past - Court / Law Enforcement Involvement

Caffeine

Nicotine

Alcohol

Amphetamine (Speed, Uppers)

Depressants (Xanax, Klonopin)

Inhalants (Whip-its, Paint, Glue)

Marijuana (Pot, Weed, Dabs, Edibles)

Narcotics (Vicodin, OxyContin, Percocet, Heroin)

Cocaine (blow, crack)

Methamphetamine (meth, crank, ice, glass, crystal)

Ecstasy (Molly, MDMA)

Is there a drug or substance your Child has used that isn't listed above? If so, please explain:

Has anyone ever complained about your Child's drug use? If so, who?

Have they ever felt guilty over their drinking / drug use?

Yes

Clear selection

Do they typically use one of these substances to "get going" in the morning?

Yes

Clear selection

Has your child ever consumed drugs/alcohol while working or at school?

Yes

Clear selection

Has their drug / alcohol use resulted in problems at work, home, school, or personal life?

Yes

Clear selection

Has your Child ever blacked out from alcohol / drug use?

Yes

Clear selection

More than 3 times?

Yes

Clear selection

Has your Child been charged with a drug/alcohol related offense?

Stress

Some questions about Chronic (ongoing) and Acute (immediate time limited) Stress.

Please list any ongoing situations or events that produce stress for you, your family, or your child:

Please list any stressful situations that have recently begun and may be effecting your child, you, or your family.

Support

Let's talk about your support system.

Please list any individuals in your life your child draws support from:

Please list any organizations, clubs, or groups that provide you or your child with support:

Please list any hobbies or activities that you or your child engage in, in order to reduce your Stress:

Religious & Spiritual Beliefs

Let's talk about spirituality.

What are your and your child's current religious belief system or affiliation, if you have one?

To what degree do your spiritual and religious beliefs impact you or this child's life?

Is there anything else you feel it's important for me to know?

Thank You!

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