What is the name of the child or adolescent?_______________________________
What is your name? _______________________________________
What is your relationship to the child? ___________________________________
What is today’s date? __________________________
Is the child male or female (or other)?_____________________
What is the child’s date of birth?_________________________________________
What is the name (or names) and relationships of other parents, stepparents, guardians, or other parental figures? Please include all, including yourself.
Name: Relationship: Lives in current household, or not:
_____________ ________________ ______________________________
_____________ ________________ ______________________________
_____________ ________________ ______________________________
_____________ ________________ ______________________________
What is the mailing address at which the child resides?
Street Address:_____________________________________________________
City:____________________________ State:__________________ Zip:__________
What is the mailing address of any other parental figure(s) who are not at the address you just gave?
Street Address:_____________________________________________________
City:____________________________ State:__________________ Zip:__________
Please list phone numbers of family members, including yourself.
Name: Phone number:
________________ _________________________
________________ _________________________
________________ _________________________
Email addresses of family members, including yourself:
Name: Email address:
________________ _________________________
________________ _________________________
________________ _________________________
Who else lives in the household with the child – for example brothers or sisters or grandparents -- and what are their dates of birth?
Name: Relation to child: Date of Birth
______________ _____________________ ________________________
______________ _____________________ ________________________
______________ _____________________ ________________________
What are the occupations of parents or caretakers?
______________ _____________________
______________ _____________________
______________ _____________________
What school does the child attend now?
What grade is the child in, in school?
Is the child in special education – that is, does the child have an IEP? If so, what designation? (By designation, we mean category such as specific learning disability, emotional disturbance, speech or language impairment, autism, hearing impairment, etc.)
Does the child have a “section 504” plan at school?
If there are special accomodations the child receives at school, what are they? (examples: one-on-one aide, extra time on tests, special ed teacher in classroom part of the time, pull-out into special ed classes part or all of the time, etc.)
What do you consider the child's race or ethnicity to be?
Is there any additional information on ethnic or cultural background of the child or the family that you would like to communicate to us?
How would you describe the presence or absence of religious affiliation or inclination of family members?
Who is the child’s primary care physician (e.g. pediatrician or family practice doctor?)
Who referred you, or how did you find out about this service?
How far did you go in school, i.e. what is your highest degree or year of education?
Is the family of low enough income to be eligible for food stamps, Medicaid, public housing, or any other kind of public assistance? If so, which?
In the space below, please write the problems you would like us to help solve, or the goals you would like us to help accomplish. (This is an important one!)
Please list any mental health diagnoses or problem labels that this child has been given, by whom, and when.
Please describe any past or ongoing mental health treatment of the child: dates, providers, interventions, and responses.
Now please summarize any medical or surgical or other health problems the child has had. Please list types of problems, dates, providers, interventions, responses, results of assessments, etc.
If the child is receiving any medication for psychiatric or behavioral or emotional purposes or concentration, please say which it is, below.
How old was the child when you first heard a complaint or concern voiced by a teacher about his or her behavior, if there have been any complaints or concerns voiced?
What psychiatric problems have there been for
mother:
father:
siblings:
other family members:
What medical problems (other than psychiatric problems) are present in:
mother
father
siblings
other family members
If you would like to communicate any stressors that anyone in the family is experiencing now, please do so below.
If you would like to communicate anything about the degree of support versus isolation that you do or do not have as a parent, please do so below.