CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT. Name of Person completing form: Relationship to client:
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1 CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT Date of appointment: Client Name: Time of appointment: Age: DOB: Gender: Male Female Transgender Preferred Name/Nickname: Ethnicity: Hispanic Non Hispanic Race: Name of Person completing form: Relationship to client: PRESENTING PROBLEM: (Briefly describe the issues/problems which led to your decision to seek therapy services). How severe, on a scale of 1 10 (with 1 being the most severe), do you rate your child s presenting problems? MOST SEVERE LEAST SEVERE PRESENTING PROBLEM CATEGORIZATION: (Please check all the apply and circle the description of symptom) Symptoms causing concern, distress or impairment: Change in sleep patterns (please circle): sleeping more sleeping less difficulty falling asleep difficulty staying asleep difficulty waking up difficulty staying awake Concentration: Decreased concentration Increased or excessive concentration Change in appetite: Increased appetite Decreased appetite Increased Anxiety (describe): Mood Swings (describe): Behavioral Problems/Changes (describe): Victimization (please circle): Physical abuse Sexual abuse Psychological Abuse Robbery victim Assault victim Dating violence Domestic Violence Human trafficking DUI/DWI crash Survivors of homicide victims Other: 1
2 Other (Please describe other concerns): How long has this problem been causing your child distress? (please circle) One week One month 1 6 Months 6 Months 1 Year Longer than one year How do you rate your child s current level of coping on a scale of 1 10 (with 1 being unable to cope)? UNABLE TO COPE ABLE TO COPE FAMILY COMPOSITION: Mother s Name: Age: Living with child Not living with child Employed Currently? Place of Employment: Occupation: Father s Name: Age: Living with child Not living with child Employed Currently? Place of Employment: Occupation: Marital status of Parents: Single Married Divorced Widowed Domestic Partnership Please list the names, ages, relationships and other relevant information regarding all immediate family members whether living in or outside the home. Please include all members currently residing in child s household. Name Gender Age Relationship To Client Living With Child 2
3 What else do you feel/believe would be helpful, or important for us to know/understand about your relationships with your family or about your family members? RECENT LOSSES: Family Member Friend Health Lifestyle Job Income Housing None Who? When? Nature of Loss? Other Losses: Additional information (if needed): PREGNANCY & BIRTH HISTORY: Were there any complications during pregnancy? If yes, please explain: Full term Birth Premature Birth Were there any complications during birth? Yes No If yes, please explain: Were drugs or alcohol consumed during pregnancy? Yes No Child s weight at birth? lbs. oz. Child s health at birth? Length of hospital stay? Post partum depression? Yes No Was your child adopted? If yes, at what age? Domestic adoption International adoption (Country: ) DEVELOPMENTAL HISTORY: As accurately as you can remember, how old was your child when she/he: Rolled over? Crawled? Walked? Talked (two words)? Toilet Trained? Do/did you have concerns about your child s development in any of these areas (below)? Speech/Language Motor Skills Cognitive/Intellectual Sensory Behavioral Emotional Social If so, please describe: 3
4 Were there any significant disturbances/changes during your child s childhood? If yes, please describe: HEALTH HISTORY How would you describe your child s overall health? Does your child have any health issues? If yes, please list below: Does your child have any recurrent medical conditions such as ear infections, asthma or allergies? If yes, please explain: Does your child have tubes in his/her ears? Include current significant medical problems, physical limitations, sleep problems, unusual eating habits, poor hygiene, overall physical fitness, head injuries, early childhood infections, eating disorders, knee or back injuries, asthma, etc.) Medical Conditions Currently receiving treatment? Provider Does this condition cause stress or impairment at this time? What have you found that helps? Does your child take any medications? Yes No 4
5 Please list medications (including psychotropic, over the counter, herbal remedies) that you have taken in the past 6 months Medication Dosage Frequency Prescribed By Reason for Medication Is your child taking the medications as prescribed? If No, please explain: Additional information (if needed): Has your child ever had a serious accident/illness or hospitalization? Yes No Please list all past hospitalizations, surgeries, accidents, or illnesses in the chart below. Reason for Previous Hospitalizations, Accident, Illness Date/Location of Hospitalization Has your child had the following screenings (please check all that apply)? Hearing Screening Vision Screening Date: Outcome: Date: Outcome: Speech/Language Screening Date: Outcome: Primary Care Doctor: Facility: Phone Number: 5
6 PSYCHIATRIC/PSYCHOLOGICAL HISTORY: Is your child currently being seen by a counselor? If yes, name of current counselor Length of Treatment Is your child currently being seen by a psychiatrist? Yes No If yes, name of current psychiatrist Length of Treatment Has your child ever been diagnosed with a mental health, emotional or psychological condition? Yes No If yes, what diagnosis was your child given? When? By Whom? Has your child received counseling services or been hospitalized for mental health or drug and alcohol concerns in the past? If yes, please list previous counseling/hospitalizations for mental health/drug and alcohol concerns below Dates of Service Place/Provider Reason for treatment Were the services helpful Additional information: SAFETY CONCERNS: Is your child presently suicidal? If Yes, please explain Has your child ever attempted to commit suicide? Yes No If yes, when and how? 6
7 Is there a history of suicide in your child s immediate and/or extended family? If Yes, please explain Has your child ever inflicted burns or wound on his/herself? Is your child presently homicidal? If yes, please explain Additional Information: (please list additional information as needed to address past and current safety issues) CURRENT FUNCTIONING: Do you have concerns about your child in the following areas? (check all that apply)? Eating Hygiene/grooming Sleeping Activities/play Social Relationships If so, please describe: Please rate your child s personality/temperament (how they behave the majority of the time in each of the following areas on a scale from 1 to 7 by placing a check above the number that best describes your child): ENERGY/ACTIVITY LEVEL (how active is my child?) CAN sit still and listen CAN T sit still and listen for long periods of time : : : : : : for long periods of time NEED FOR PHYSICAL ROUTINE (how much routine does my child need)? ENJOYS DOING THINGS ENJOYS ROUTINE; easily DIFFERENTLY; may not upset when day doesn t : : : : : : notice small changes in go as usual the day 7
8 MOOD (what is my child s mood most of the time)? ANXIOUS usually frustrated and worried : : : : : : CALM usually relaxed HAPPY usually enjoys SAD usually unhappy; what he/she is doing : : : : : : hard time having fun CURIOUS usually eager TIMID usually not to know something : : : : : : interested ANGRY easily frustrated CALM usually and annoyed with others : : : : : : composed and peaceful with others INTENSITY (how strongly does my child express feelings, wants and opinions?) MILD REACTION calm STRONG REACTIONand cooperative; Easily : : : : : : may cry or yell over pushed around by others small things PERSISTENCE (Can my child stick with and complete tasks?) Will stick with something Gives up on tasks; until it is done : : : : : : has trouble finishing things SENSITIVITY TO SENSES (How sensitive is my child to light, smells, sounds, and touching?) Learns by seeing Has strong reaction to touching and using all : : : : : : noise, lights, hugging his/her senses or touching PERCEPTIVENESS (How aware is my child of feelings and emotions?) Sympathetic to others; Unaware of the can use words to tell : : : : : : feelings of others how he/she feels
9 ADAPTABILITY (How easily does my child accept changes?) Often fearful with new Will easily meet and people and new : : : : : : accept new people and situations activities ATTENTION SPAN/DISCTRACTIBILITY (How well does my child pay attention?) Stays focused on tasks Easily sidetracked; until completed : : : : : : difficulty following directions PARENT/CHILD RELATIONSHIP Describe parenting your child (e.g. challenging, easy): What do you find most challenging in parenting your child? What kind of discipline works best with your child? EDUCATION Is your child currently enrolled in school? Yes No Name of School What grade is your child currently in (if summer, was grade is your child going into)? How would you describe your child s attendance (currently)? (circle ALL that apply) Attending regularly Home schooled Some truancy Alternative school Suspended Expelled Dropped Out GED program How would you describe your child s achievement/grades in school? How would you describe your child s attitude towards school/education? Disciplinary or behavioral issues at school? If yes, describe: Please check if your child has any of the following? Special Education Accommodations or a 504? Please describe: An Individualized Education Plan (IEP)? Diagnosed Learning Disability? Receiving special services at school? Please describe: Please describe: Please describe: 9
10 EMPLOYMENT: Is your child currently employed? If employed, where are they working? How long? Does your child enjoy their current job? HOUSING: Would you consider your housing to be: stable unstable If unstable, please describe: Please choose the one that best describes the current housing arrangement for this child: Parent/Guardian owns home Parent/Guardian rents home Child and family live with relatives/friends (temporary) Child and family live with relatives/friends (permanent) Homeless Transitional Housing Emergency Shelter How long has this child lived in the current living situation? How many times has the child moved in the past two years? What else do you think is important for us to understand about your housing/living situation? FOSTER CARE INVOLVEMENT: Has your child ever been in foster care? Unknown From age to age Reason: Type of Placement: Familial Placement Non Familial Placement Current Status: In Care Out of Care If Out of Care, reason for leaving: Adopted Returned to Home Emancipated Ran away from care Other: 10
11 FAMILY MENTAL HEALTH HISTORY Please identify if any members of your family have had a history of any of the following mental health/drug abuse/legal concerns. Family History Depression Anxiety Bipolar Disorder Schizophrenia ADHD/ADD Trauma History Abusive Behavior Alcohol Abuse Drug Abuse Incarceration Self Mother Father Sister Brother Maternal Uncle Paternal Uncle Maternal Aunt Paternal Aunt Maternal Grandmother Paternal Grandmother Maternal Grandfather Paternal Grandfather Biological Child Additional Information: ALCOHOL/DRUG ASSESSMENT: Does your child use tobacco or smokeless tobacco? Do not know Does your child use alcohol or drugs? Do not know To your knowledge, has your child ever used medications (prescriptions drugs or over the counter medication) recreationally? Do not know 11
12 To your knowledge, has your child ever overdosed or passed out on alcohol or other drugs? If yes, when was the last overdose? Has your child ever experienced problems related to their alcohol use? If yes, please check area and describe problems: Legal Social/Peer Work Family Friends Financial Please describe: If yes, have they continued to drink/use drugs? LEGAL INVOLVEMENT: Is there a current custody case involving your child? If yes, please describe below. History of CPS involvement: None Past Current Please describe below. Please indicate by checking your child s legal status below. No Involvement No Involvement Probation Length: Parole Length: Charges Pending Prior Incarceration Law Suit or other Court Proceeding Charges: Probation/Parole Officer s Name: Contact #: Additional Information: HISTORY OF ABUSE/NEGLECT: Has your child ever been abused or assaulted? If Yes, please complete the chart below. Type of Abuse By Whom? (relation to child if any) At What Age? Was it Reported? Sexual Physical Emotional Verbal Abandoned/Neglected Has your child ever been a victim of bullying? Do you worry about your child s safety now? 12
13 What else do you feel is important for us to know? HISTORY OF VIOLENCE: Has your child ever been accused of abusing or assaulting someone? chart below. If yes, please complete Type of Abuse To Whom? Age of your child? Was it Reported? Sexual Physical Emotional Verbal Abandoned/Neglected Has your child ever been known to bully other children? What else do you feel/believe is important for us to know? STRENGTHS/RESOURCES/SUPPORTS: What limitations does your child/ family have (if any)? What strengths does your child/family have? What resources does your child have to help with your current problem? What experiences (past & present) will help you in improving the current situation? What are you (and your family) already doing to improve the current situation? Who does/can your child count on for support? Parents Boyfriend/Girlfriend Siblings Extended Family Friends Neighbors School Staff Church Pastor Therapist Group Community Services Doctor Other: 13
14 CURRENT NEEDS/GOALS What do you feel is your child s biggest need right now? What do you most hope to gain from coming to counseling? If you were to pick three goals to work on, what would they be? Goal 1: Goal 2: Goal 3: What else would you like for us to be aware of? INDIVIDUAL(S) COMPLETING ASSESSMENT Printed Name (primary person) Date: Signature Relationship to child Printed Name (secondary person) Date: Signature Relationship to child 14
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