Therapist: Child History Form. PATIENT IDENTIFICATION First Appointment Date Birth Date Age Sex School Grade
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1 Therapist: Child History Form In order for us to be able to fully evaluate your child, please fill out the following questionnaire to the best of your ability. We realize there may be information that you do not remember or have access to; do the best you can. Thank you! PATIENT IDENTIFICATION Name First Appointment Date Birth Date Age Sex School Grade Religion Natural Mother Race Natural Father Address City State Zip Home Phone # Work # Cell# Who is the child currently living with? REFERRAL SOURCE Referral Source Referral Address Phone # Do we have your permission to release information to the referring professional when it is appropriate? Yes No PURPOSE OF THE CONSULTATION (Please give a brief summary of the main problems) WHY DID YOU SEEK THE EVALUATION AT THIS TIME? PRIOR ATTEMPTS TO CORRECT PROBLEMS / PRIOR PSYCHIATRIC HISTORY (Please include contact with other professionals, medications, types of treatment, etc.) What do you want this clinician to do for your child, yourself or your family?
2 2 MEDICAL HISTORY Current medical problems/medications Past medical problems/medications Other doctors/clinics seen regularly Any history of head trauma? (describe) Ever any seizures or seizure like activity? Any periods of spaciness or confusion? Prior hospitalizations (place, cause, date, outcome) Prior abnormal lab tests, X-rays, EEG, etc. Allergies/drug intolerances (describe) Present Height: Present Weight: FAMILY HISTORY Family Structure (who lives in the current household with the child, please give relationship to the child): Family Development (include marriages, separations, divorces, deaths, traumatic events, losses, etc.) Current Marital Situation/Satisfaction of Parents Natural Mother s History: Age Outside Work
3 3 Has mother ever sought psychiatric treatment? Yes No Mother s alcohol/drug use history Have any of mother s blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) Natural Father s History: Age Outside Work Has father ever sought psychiatric treatment? Yes No Father s alcohol/drug use history Have any of father s blood relatives ever had any learning problems or psychiatric problems including such things as alcohol/drug abuse, depression, anxiety, suicide attempts, psychiatric hospitalizations? (specify) (If Applicable) Step or Adoptive Mother s History: Age Outside Work
4 4 Has step or adoptive mother ever sought psychiatric treatment? Yes No Step or adoptive mother s alcohol/drug use history Step or Adoptive Father s History: Age Outside Work Has step or adoptive father ever sought psychiatric treatment? Yes No Step or adoptive father s alcohol/drug use history Siblings (names, ages, problems, strengths, relationship to patient) Family Stresses (Please list current factors that are a source of stress in the family) CHILD S DEVELOPMENTAL HISTORY Prenatal events: Parents attitude toward pregnancy Conception ease planned unplanned Pregnancy complications (bleeding, excess vomiting, medication, infections, x-rays, smoking, alcohol/drug use, etc. Birth and Postnatal period: Birth weight Length Labor duration Delivery: vaginal C-Section Problems APGAR scores (if known) Any jaundice? Yes No
5 5 Time in hospital Any other complications? Mother s health after delivery Post delivery blues? If yes, how long? Primary caretaker for child, first year Thereafter Feeding history: breast vs. bottle age weaned Food allergies Current eating problems Sleep behavior: sleepwalking, nightmares, recurrent dreams, current problems (getting up, going to bed) Separations from mother and/or father: age, duration, reaction to: Motor development: (please write in age events occurred; ages in parentheses are approximate normal limits) Rolls over (3-5m) Sits without support (5-7m) Crawls (5-8m) walks well (11-16m) Runs well (2y) rides tricycle (3y) Throws ball over hand (4y) Current level of activity Fine and gross motor coordination Compared to peers Language development: Several words besides dada, mama (1y) Name several objects ball, cup (15m) 3 words together subject, verb, object (24m) Vocabulary Articulation Comprehension Compared to peers Any current problems
6 6 Social development: Smile (2m) shy with strangers (6-10m) Separates from mother easily (2-3y) Cooperative play with others (4y) Quality of attachment to mother Quality of attachment to father Early peer interactions Current peer interactions Special interests Relationships to family members Hobbies/interests Toilet training: Age reached bowel control: day night Age reached bladder control: day night Methods used ease Current function Sexual development: Gender identity Any problems Behavioral/Discipline: Compliance vs non-compliance Lying/stealing Methods of discipline Other problems rule breaking Emotional development: Early temperament Current personality Mood Habits Fears/phobias Special objects (blankets, dolls, etc.) Ability to express of feelings
7 7 Physical /Sexual Abuse: Drug/Alcohol History School History: Current grade School contact Number of schools attended Average grades Homework problems? Specific Learning disabilities Strengths Motivation What have teachers said about the child/teen Overall strengths as viewed by parents Overall strengths as viewed by the child/teen
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INTAKE FORM. General Information Name DOB Date Address: Phone: Cell Phone: Email:
INTAKE FORM General Information Name DOB Date Address: Phone: Cell Phone: Email: Marital Status (Circle One) Single Engaged Married Separated Divorced Widowed If married how long? Number of previous marriages
Ellyn L. Turer, PsyD, PLLC 1320 19 th Street, NW Suite 202 Washington, DC 20036 Tel: 202-293-6463, ellyn-turer@hushmail.com
Date CLIENT INFORMATION Client Name Address City State Zip Code Primary Contact Ph # Cell Home Work Secondary Ph # Cell Home Work Email Address Do you text? Yes No Birth date Social Security Number Occupation
Other Children: (not in home) Name Age Relationship Job/School Mental Health History Relationship with Child (positive, conflicted, etc.
Psychological and Life Skills Associates, PC 13885 Hedgewood Drive, Suite 245, Woodbridge, VA 22193 601 Jefferson Davis Hwy, Suite 101, Fredericksburg, VA 22401 (703) 490-0336 CHILDREN/ADOLESCENT INTAKE
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
CHILD S FACE SHEET/ENROLLMENT FORM INFANT/TODDLER
CHILD S FACE SHEET/ENROLLMENT FORM INFANT/TODDLER CHILD INFORMATION: Child s Name: Date of Birth Home Address: Place of Birth:(city/town) Telephone: Primary Language: Child s Identifying Information (required
If baby was born 3 or more weeks prematurely, # of weeks premature: Last name: State/ Province: Home telephone number:
Ages & Stages Questionnaires 10 9 months 0 days through 10 months 30 days Month Questionnaire Please provide the following information. Use black or blue ink only and print legibly when completing this
PAIN MANAGEMENT. Patient s name: IF YOUR INSURANCE REQUIRES A PRE AUTHORIZATION / REFERRAL FORM, PLEASE OBTAIN PRIOR TO YOUR VISIT.
PAIN MANAGEMENT Please fill out the following questionnaire and bring it with you to your appointment. In addition, bring your medication list and Reports of any X- rays, MRI or Cat scans. Patient s name:
YOUTH MENTORING PROGRAM. Mentee Application (To Be Completed by the Parent/Guardian)
Personal Information YOUTH MENTORING PROGRAM Mentee Application (To Be Completed by the Parent/Guardian) Youth s Name: Date: Parent/Guardian Name: Relationship to Youth: Mother Father Other, specify: Street