Presenting Problems Describe the top three concerns that led you to obtain this evaluation
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- Peregrine Jackson
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1 John P. Godfrey, Ph.D. Psychologist 3305 Northland Drive, Suite 509 Austin, TX tel (737) fax (737) CHILD AND ADOLESCENT FAMILY-REPORT HISTORY Revised 2016 To be completed by parent or legal guardian Today s Date Identifying Information Child s Name Nickname (Optional) Child s Age: years months Date of Birth Child s Sex o Male o Female Racial/Ethnicity/Cultural Identity (Optional) Parent s/legal Guardian s Name(s) This form was completed by My relationship to this child is: obiological Mother obiological Father ograndmother ograndfather o Legal Guardian oadoptive Mother oadoptive Father ofoster parent oother Telephone Contact Numbers (mark x below to indicate your preferred contact number(s)) Name Relationship (Mom/Dad/Step/Other) o Home ( ) Ask for o Work ( ) Ask for o Work ( ) Ask for Presenting Problems Describe the top three concerns that led you to obtain this evaluation Briefly describe the history of the problems your child is showing (when they began, how often, how long?) Has your child ever been hospitalized for psychiatric problems or chemical dependence? ono oyes If xyes, please list the diagnosis, when and where hospitalized and who treated your child: Has your child ever been treated as an outpatient by a psychiatrist, psychologist, therapist, counselor or EAP? ono oyes If xyes, please list his or her diagnosis, when given, and by whom: Has your child ever been ordered to treatment (such as by a judge or court)? ono oyes Has your child ever been subject of any legal charges (past, pending or current)? ono oyes Are you seeking an evaluation for legal purposes (e.g., a child custody dispute)? ono oyes Is your child s current school status in jeopardy? ono oyes Problem Checklist (check all that apply) o Impulsive behavior o Accident prone o Denies responsibility Note: Problem checklist continues on next page Children Adolescents Adults Families ADHD throughout the Lifespan
2 Problem Checklist, continued (check all that apply) o Unusual or severe fears o Is excessively particular about the order or way in which things are done o Says or does unusual or bizarre things o Preoccupation with topics, objects, parts of objects or machines o Often sick on school days o Behaves or dresses, or plays unlike children of same age o Sets fires or plays with fire o Steals within the household o Steals outside the household o Commits vandalism, or breaking and entering o Hurts or kills animals o Wets the bed o Soils underwear o Difficult to awaken in the morning o Difficult to get to sleep o Snores frequently while sleeping o Often sleepy during the day o Recent change in appetite o Increased o Decreased o Other: o Eats non-food substances o Run away from home or stays out all night without permission o Unexpected or unintended weight gain or loss during past month o Limited or no interest in friends o Difficulty retaining friends o Sexual preoccupation o Sexual knowledge or behavior that is unexpected for age o Excessive concerns about germs, cleanliness, orderliness, possible danger or harm to family members o Other Family Information Family Members & Other People Residing with the Child in his/her primary residence(s) Name Age Relationship to child Occupation Family members who DO NOT Reside with the Child in his/her primary residence(s) Name Age Relationship to child Location (City/State) Describe child s overall relationships & interactions with family members (parents, siblings, others at home): o Excellent o Good o Fair o Poor Comments: (include any specific concerns or chronic conflicts) Peer Relationships Briefly describe child s overall relationships with peers o Excellent o Good o Fair o Poor Comments - 2 -
3 School Information Grade Name of School School District Recent Academic Functioning o Excellent o Good o Fair o Poor Current Grades Current classes/programs/services your child is attending: o All Regular Classes o Early Childhood ogifted/talented o504 (OHI) o Special Education o Resource ospeech Therapy ocontent Mastery o Tutoring o Honors/Pre-AP/AP oreading/math assistance o Self-Contained or Behavior Management oalternative placement (e.g. ALC/RROC) o Other Past classes/programs/services your child has received: o All Regular Classes o Early Childhood ogifted/talented o504 (OHI) o Special Education o Resource ospeech Therapy ocontent Mastery o Tutoring o Honors/Pre-AP/AP oreading/math assistance o Self-Contained or Behavior Management oalternative placement (e.g. ALC/RROC) o Other Previous schools attended? o No o Yes If yes, then describe: School Name City-State Ages(s)/grade(s) Has your child ever been retained (held back) or promoted ( skipped ) up a grade? o No o Yes School Behavior Describe your child s current at school behavior (or daycare): o Teachers report frequent problems with following rules o Teachers report frequent problems with maintaining attention and concentration o Child shows difficulty completing work in class o Child frequently complains of illness at school o Child shows difficulty remembering and turning in assignments o Child has been aggressive at school (such as pushing, kicking, hitting, biting, spitting) o Child has been suspended of times for alleged misbehavior o Child has been expelled of times for alleged misbehavior o Child hates school o Child fears school o Other o Other Medical and Developmental History Pregnancy/Gestation Age of mother at child s birth Number of previous pregnancies Problems/Conditions/Illnesses for mother during pregnancy (check all which apply) o Anemia o Pre-eclampsia or Eclampsia o Placenta Previa o Gestational Diabetes o Hypertension o Other o Use of tobacco [When x d, indicate about how much and how often?] o Use of alcohol [When x d, indicate about how much and how often?] o Other drugs o Medications taken during pregnancy Other medical problems for mother during pregnancy or gestation Delivery Term of pregnancy: o Full o Premature ( # of weeks) o Overdue ( number of weeks) Birth weight Overall health of infant at birth: o Excellent o Good o Fair o Poor Additional details (such as APGAR score) - 3 -
4 Medical and Developmental History (Continued) Unusual circumstances or complications during birth/delivery? (check all that apply) o Induced o Caesarean o Meconium o Fetal distress o Anoxia (low oxygen) o Breach o Jaundiced o Cord around neck o Forceps o Other Time in hospital after delivery: o days o weeks Time in incubator o days o weeks Infant Health History (age birth to one year) Check all which apply with ages o High temperature(s)/fevers Ages o Pneumonia Ages o Seizures/ Head injuries Ages o RSV o Other o Lung or breathing problems (asthma) Ages o Colic Ages o Ear infections Ages o Allergies to medicines o resolved o unresolved o Allergies to foods o resolved o unresolved o Other allergies o resolved o unresolved o Difficulty with Feeding/Describe: o Hospitalizations/Surgeries: reason, age, outcome What was the emotional atmosphere like in the home during the child s first few years? (tense, relaxed, etc.) Toddler History (age one to three years) Approximate ages at which your child: Sat Alone Crawled Walked Spoke in single words Spoke Simple Sentences Age at which toilet training was begun Age Completed Significant problems (if any) Activity Level: o Low o Medium o High o Hyperactive o Other Child s Temperament (please check all that apply): o Easy o Resisted changes o Positive/cheerful o Stubborn o Easily distracted o Persistent o Negative o Serious o Easily Bored o Easily frustrated o Anxious/tearful o Clinging /trouble with separation o Difficult to soothe o Sensitive to sounds or textures o Demanding o Upset by changes/transitions o Cranky o Regular in habits o Easily engages with others o Shy or avoidant o Reacts intensely o Generally calm o Gives up easily o Other Family Mental Health Inventory Please list the diagnoses given to the patient s extended family members (their so-called blood relatives ) o Schizophrenia o Bipolar or Manic-Depression o Depression o Anxiety or Panic o Alcohol/drug abuse o Obsessive Compulsive Disorder o ADHD or ADD o Suicide o Learning disorders (dyslexia) o Intellectual Disability o Nervous breakdown o Other For each of the diagnoses/disorders listed above, describe the family member s relationship with the patient (such as their mother, father, grand- and/or great-grandparents, aunts, uncles, cousins, nieces & nephews, and so on). Note: Texas State Law requires therapists and MDs to report allegations or suspicions of abuse to a minor child regardless how long ago such abuse may have occurred - 4 -
5 Abuse or Exposure to Violence My child has been abused? o No o Yes o Verbally o Emotionally o Physically o Sexually My child has been a witness to violence o No o Yes When answering Yes, please describe briefly: Has abuse been reported to CPS or police? o No o Yes Were charges filed? o No o Yes Has your child experienced a traumatic event (e.g., accidents, illnesses, losses, separations, or deaths) that resulted in a notable change in behavior or mood: o No o Yes If Yes, please describe: Current Illnesses or Medical Conditions (Age of Onset, treatment) Current Medications (kind, dosage, prescribing MD, effectiveness) Past Medications (kind, dosage, prescribing MD, effectiveness) Adolescents Females: Menses begun o yes o no Sexually active o yes o no Males: Secondary sexual traits manifest o yes o no Sexually active o yes o no Uses drugs, alcohol, tobacco? - 5 -
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