Child And Adolescent History Form Step 1 of 13 7% General InformationName* First Last PhoneEmail Date of Birth* MM slash DD slash YYYY Gender* Nationality* Name of person completing form* First Last Relationship to child* Reason for referral: What are your primary concerns?* Parents & FamilyParent 1 Name Level of Education Occupation Employer Parent 2 Name Level of Education Occupation Employer Parents are* Married Never Married Separated Divorced Living Together Other Legal Custody* Joint Mother Father County Foster Parent Other Physical Custody* Joint Mother Father County Foster Parent Other Other Parent(s)/Stepparent(s)/Caregiver(s)Name Relationship to child Name Relationship to child Please list all siblings or others living with the familyName Relationship Age Name Relationship Age Name Relationship Age Please list all siblings not living in the homeName Relationship Age Name Relationship Age Name Relationship Age Has your child experienced neglect or abuse? Yes No Suspected Unknown If there has been any abuse or trauma experienced check all that apply. Physical Abuse Sexual Abuse Emotional Abuse Verbal Abuse Bullying Life-Threatening Situation Other Trauma Has your child ever lost someone with whom s/he had a close relationship, (e.g. a parent, sibling, etc.)? Have there been any recent stressful life events? (Check all that apply) Divorce/Separation Financial Problems Substance Abuse Death of Family/Friend/Pet Marriage Change in Job Status Disagreement About Parenting Relationship Conflict Sibling Conflict Other Birth HistoryMother’s age at time of child's birth: Did mother receive prenatal care? Medications taken during pregnancy? (Please specify): Were any of the following used during pregnancy? (Including prior to knowledge of the pregnancy) Alcohol Marijuana Tobacco Methamphetamines Other Drugs Please explain any complications during pregnancy, labor or delivery Method of delivery (vaginal, cesarean, forceps, vacuum) Full term/early/late Child’s birth weight and length Were there any complications before the baby was taken home? Did the baby spend any time in the NICU, and if so for what? Any additional comments Any history of foster care/orphanage care/CPS involvement? If child is adopted, Age at adoption Contact with biological parents? Additional comments Developmental HistoryWhich hand does your child prefer Right Left Did your child ever have any motor coordination difficulties (e.g. frequent falling, awkwardness)? Yes No Did your child have any difficulty in learning to talk or have any speech problems? Yes No At what age did your child develop gross motor skills (crawling, walking)? At what age did your child develop fine motor skills (fingers / hands)? At what age did your child develop communication skills? At what age did your child develop self-care (dressing self, taking care of hygiene)? At what age did your child develop social skills? At what age did your child develop education skills (alphabet, numbers)? At what age was your child toilet trained? Has your child had problems with the following? (Check all that apply) Limited social interest Narrow range of interests Self-harm Withdrawn behavior Repetitive or odd behaviors Aggressive behaviors Tantrums Loss of developmental skills Shyness Poor eye contact Limited self-regulation Specific fears Additional Comments Medical HistoryDoes your child have or has s/he ever had meningitis?* Yes No Does your child have or has s/he ever had head injuries/concussions?* Yes No Does your child have or has s/he ever had ear infections?* Yes No Does your child have or has s/he ever had asthma?* Yes No Does your child have or has s/he ever had diabetes?* Yes No Does your child have or has s/he ever had loss of consciousness?* Yes No Does your child have or has s/he ever had high fever?* Yes No Does your child have or has s/he ever had heart disease?* Yes No Does your child have or has s/he ever had seizures?* Yes No Does your child have or has s/he ever had lead poisoning?* Yes No Does your child have or has s/he ever had any other Illness?* Yes No Please describe treatment given and any complications for illnesses/injuries indicated above Has your child ever been hospitalized?* Yes No Describe any hearing or vision problems List any previous surgeries, child’s age, and length of hospitalization Other medical history Does your child frequently complain of or have problems with (check all that apply) Headache Weakness Fatigue or Sleep Issues Dizziness Nausea Wetting/Soiling Accidents Stomach Aches Diarrhea Muscle Tension Current Medications For what has this medication been prescribed? Side Effects Who prescribes this medication? Previous medications & dates taken Has anyone in your family had a neurological disease?* Yes No Has anyone in your family had seizures (epilepsy)?* Yes No Has anyone in your family had psychiatric problems?* Yes No Has anyone in your family had emotional problems?* Yes No Has anyone in your family had alcoholism problems?* Yes No Has anyone in your family had substance abuse problems?* Yes No Has anyone in your family had language delays?* Yes No Has anyone in your family had motor (physical) delays?* Yes No Has anyone in your family had hyperactivity?* Yes No Has anyone in your family had learning problems?* Yes No Has anyone in your family had autism spectrum disorders?* Yes No Has anyone in your family had similar problems to child?* Yes No Evaluation & ServicesFor each category, please list any previous evaluations, examiners, dates, and results, as well as current providers.Pediatrician or Family Doctor TelephoneFaxTherapist/Examiner's Name Title TelephoneFaxDates of Last Evaluation/Sessions Date of Evaluation Occupational Therapy/Physical Therapy/Speech & Language TherapyClinic Name & Examiner's Name Therapy: Dates attended Dates of Last Vision/Hearing Examination Neurologist's Name Date of Last Examination County Social Worker/Case Manager Name TelephoneFaxOther SchoolName of Child’s Current School Grade Main Teacher or Counselor Has your child completed an evaluation through school (e.g., to qualify for special education)?* Yes No Name of Preschool Dates Attended Concerns Name of Elementary School Dates Attended Concerns Name of Middle/Junior High School Dates Attended Concerns Name of High School Dates Attended Concerns Has your child received Title 1 services?* Yes No Has your child had a 504 plan?* Yes No Has your child had an IEP (special education services)?* Yes No Has your child received tutoring?* Yes No Check the word that best describes your child’s grades throughout his/her school experience* Superior Above Average Average Below Average Failing Has school reported current problems with (check all that apply) Reading Arithmetic Social Adjustment Writing Attention Span Following Directions Spelling Activity Level Truancy Suspension Detention Other Emotional/Behavioral ConcernsDoes your child have a history or currently struggle with (check all that apply) Depression/Sad Mood Anxiety/Worries/Nervousness Anger Attention and Focus Issues Significantly Elevated Moods Ritual or Routine Behaviors Obsessive Thinking Hallucinations Suicidal Ideation Self-Harm Behaviors Homicidal Ideation Rule Breaking Argumentative Social Concerns Hyperactivity Temper Tantrums Irritability Panic Attacks Impulsivity Distressing Memories Separation Issues Complaints of Physical Symptoms Nightmares Eating Issues Substance Use HistoryHas your child used alcohol?* Yes No Has your child used cannabis?* Yes No Has your child used meth?* Yes No Does your child consume caffeine?* Yes No Has your child ever participated in inpatient or outpatient chemical dependency treatment?* Yes No Interpersonal RelationshipsYour child's relationship status Your child's Sexual Orientation/Gender Identity NameThis field is for validation purposes and should be left unchanged.
