l Special l Regular l Combination l Chapter 1 l Individual educational plan evaluation l Parent home l Foster home l Residential facility l Other l No
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1 Patient name MHN DOB Age Gender Child/Adolescent Psychiatric/MH Questionnaire Page 1 of 9 Appointment date (month/day/year) Therapist Address School Grade Class arrangement: l Special l Regular l Combination l Chapter 1 l Individual educational plan evaluation Current living arrangement: l Parent home l Foster home l Residential facility l Other Name Caretaker/Relationship Name Caretaker/Relationship Address Address Home phone number Home phone number Work phone number Work phone number Parent or legal guardian (person legally authorized to sign for medication and treatment) Address and phone number if different than above Referral source Referred by Child s primary physician Address Would you like a copy of the evaluation from this appointment sent to the child s doctor: l Yes Would you like a copy of the evaluation from this appointment sent to someone else: l Yes If yes, specify to whom
2 Psychiatric/MH Questionnaire (Continued) Page 2 of 9 Concerns What concerns/problems do you wish to discuss in the appointment What do you believe caused these problems How long have you been concerned about your child or teenager What are your goals for the appointment Review of symptoms Check (3) any of the following areas that may create a major issue for your child or teenager: l Frequent interruption of adult conversation l Impulsive and always on the go l Hyperactive or unable to sit still l Fails to give close attention to details or makes careless mistakes l Forgetful l Daydreaming l Defiance and disobedience l Frequent temper tantrums l Problems making friends in neighborhood l Problems making friends in school l Aggression to self l Self abuse/mutilation l Aggression to others, specify l Destruction of property l Animal cruelty l Lying l Stealing l Fire setting l Running away from home l Running away from school l Police/Legal trouble l Concern about drugs l Concern about alcohol l Tobacco use/smoking l Depression, sadness or unhappiness l Extreme mood swings l Withdrawal l Irritability l Body aches, headaches, stomachaches l Frequent crying l Suicide attempt l Thoughts of suicide l Negative comments about self l Sleep problems l Appetite problems l Worries l Nightmares l Shy or timid l Nail biting
3 Psychiatric/MH Questionnaire (Continued) Page 3 of 9 l Bed wetting/soiling l Repeats certain act over and over l Avoid certain things or places l Uncomfortable in social situations l Panic attacks l Prefers younger children as playmates l Prefers older children as playmates l Developmental delays l Speech problems or delays l Collects things, specify l Misinterprets ideas l Strange behavior, explain l Suspiciousness l Paranoia l Unusual thoughts or ideas Check (3) if your child has any of the following school problems: l Learning problems l Lack of interest in school l Skipping school l School suspension l Below average grades l Reading problems l Refusal to go to school l Behavioral problems in school l Repeated any grade (what grade ) Psychiatric history Have you ever tried therapy for your child or teenager: l Yes If yes: 1. Name of therapist When Where For what problems Outcome 2. Name of therapist When Where For what problems Outcome 3. Name of therapist When Where For what problems Outcome
4 Psychiatric/MH Questionnaire (Continued) Page 4 of 9 Has your child ever been hospitalized for behavioral or emotional problems: l Yes If yes: When Where Reason Does your child have any psychiatric diagnosis: l Yes If yes, what Is your child currently on medications: l Yes If yes: Name of Medication Dosage Has your child been on medications for behavioral or emotional problems in the past: l Yes If yes, list Any adverse reaction to any of the medications: l Yes If yes: Name of Medication Effect
5 Psychiatric/MH Questionnaire (Continued) Page 5 of 9 Abuse history Has your child ever experienced any abuse: l Yes If yes, type of abuse: l Physical l Sexual l Emotional l Neglect Any past dangerous behavior: l Yes If yes, specify Any past psychological testing: l Yes If yes, where (bring copy of report to evaluation) Has your child ever been placed in a foster home, group home, or residential treatment center: l Yes If yes: Where When Medical history Check (3) any of the following that your child has experienced: l Meningitis l Encephalitis l Seizure/Convulsion l Ear infection l Tubes placed in ears l Sinus infection l Pneumonia l Asthma l Heart disease/problem l Nervous twitches or tics l Tremor l Recurrent headaches/stomachaches l Severe injuries or broken bones l Lead poisoning l Hearing problems l Vision problems l Concussion l Head injuries l Skull fracture Hospitalizations/Operations Age Description
6 Psychiatric/MH Questionnaire (Continued) Page 6 of 9 Allergies: l Yes If yes, specify Immunizations up-to-date: l Yes For adolescent females only: Onset of menstrual period: l Yes Have menstrual periods been unusual or irregular: l Yes Any past pregnancies: l Yes Developmental history Child s mother had a total of pregnancies and has living children. Any complications with pregnancy: l Yes If yes, specify Did mother have any fevers, illness, or infections: l Yes Was mother exposed to medications: l Yes If yes, what Was mother exposed to x-ray: l Yes Did mother use alcohol or illicit drugs during pregnancy: l Yes Did mother use tobacco during pregnancy: l Yes Pregnancy was for how long: l Full term l Preterm l Post term Delivery was: l Vaginal l C-section l Forceps How long did labor last Apgar score (if you remember) Birth weight Length Any complications postpartum such as infection, bleeding, postpartum depression (baby blues): l Yes If yes, specify Baby: l Came home on time l Was transferred to an NICU for days Looking back through infancy and early childhood, how would you describe activity level: l High l Low l Average Did the baby cry more than average: l Yes Was the baby colicky : l Yes Did the baby have any problems bonding: l Yes Trouble with feeding: l Yes Trouble with sleep: l Yes If yes, what age How would you describe his/her temperament: l Easy baby l Difficult baby l Challenging baby l Slow to warm up l Colicky l Moderate
7 Psychiatric/MH Questionnaire (Continued) Page 7 of 9 Looking back to the first 1 2 years of your child s life, how would you describe your child s development (sitting, walking, talking, toilet training, etc.): l Mostly on time or early l Mostly late or delayed l On time, except Did your child have any problems separating from you: l Yes Head banging: l Yes If yes, what age Early childhood program: l Yes If yes, specify Attending pre-k: l Yes Social history Aggressive: l Yes Mixes well with other children: l Yes Made good eye contact: l Yes Any other thing in his/her childhood Family history of psychiatric problems Check (3) all that apply: Anxiety Psychiatric Problems Mother Biological Father Relative (Specify) Psychiatric Problems Hallucinations Biological Mother Father Relative (Specify) Depression Tourette s/tics Mood swings School problems Manic depression Suicide attempt Arrest, legal problems, felonies Alcohol use Mental retardation Drug use Eating disorders Hyperactivity Panic attacks Temper problems Seizure or epilepsy Paranoia Gambling
8 Psychiatric/MH Questionnaire (Continued) Page 8 of 9 Family membership Who does your child live with now: Name Age Relationship to Child Education Occupation Health Birth parent information (if not listed above): Birth Parent Name Age Education Job Mother Father Family stressors Check (3) if any of the following have occurred in the last 12 months: l Parents separated l Parents divorced l Parental conflict l Family moved l Child changed school l Parent changed/started job l Death of a family member or friend l Exposure to violence l Other Marital information Parents are: l Married l Separated l Divorced l Never married l Cohabitating (live together) Who has legal custody: l Both parents l Mother l Father l Other, specify Visitation schedule
9 Psychiatric/MH Questionnaire (Continued) Page 9 of 9 Social information How does the child or teenager relate to his/her friends How does the child or teenager relate to his/her siblings What is your child s strengths (talents, hobbies, interests) Thank you for taking time to complete this questionnaire. / / Patient signature (Patient s legal representative) (Relationship) Date (month/day/year)
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