CHILD (AGES 2 11) PATIENT HISTORY
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1 The Jones Center for Children s Therapy and Assessment Jessica O. Jones, PsyD, LPC-S & Alyssa R. Scott, PsyD 604 Strada Circle, Mansfield, TX Phone: (817) Fax: (817) Website: contactus@jonesccta.com CHILD (AGES 2 11) PATIENT HISTORY Name: Ethnicity: DOB: Age: Dear Parent, To help establish your child with our practice, please provide us with his/her complete medical and mental health history. Thank you and we look forward to working with you and your child! In your own words, please describe why you are seeking services for your child: Were you referred by an outside source, such as a pediatrician? Who? Family Members/Others Residing in Home Age Relationship to Child How does this child get along with other family members in the home? Defiant? Antagonistic? Alliances? Other problems? Family Members/Others Residing Outside Home Age Relationship to Child How does this child get along with family members/important people residing outside the home? Parents /Legal Guardians Marital Status: Married Divorced Separated Never Married Other: If separated or divorced, how old was your child at the time of occurrence? How did he/she adapt to the change? Maternal Family Psychiatric History (If so, who?) Suicidal ideation/attempt Anxiety/excessive worry Posttraumatic Stress Disorder Bipolar Disorder Schizophrenia Paternal Family Psychiatric History (If so, who?) Suicidal ideation/attempt Anxiety/excessive worry Posttraumatic Stress Disorder Bipolar Disorder Schizophrenia JCCTA Page 1
2 Attention problems/adhd Learning problems Autism Spectrum Disorder Alcohol/drug abuse Problems with the law Seizures Other Attention problems/adhd Learning problems Autism Spectrum Disorder Alcohol/drug abuse Problems with the law Seizures Other Does this child have a sibling(s) or half-sibling(s) who suffers any of the aforementioned psychological issues/disorders? Y or N If yes, who and what? Birth History Was the pregnancy planned? Y or N Desired? Y or N Prenatal care received? Y or N Is he/she adopted? Y or N Complications during pregnancy? Y or N If Yes, please explain: Nausea: Vomiting: Swelling: Headaches/migraines: Diabetes: Other illnesses: Bed rest: How long? Tobacco use: How much: Alcohol use: How much: Prescription drug use: What: Illicit drug use: What: Length of pregnancy: Was labor induced? Y or N If Yes, why? How was he/she delivered? (i.e., vaginally, with forceps, with vacuum assistance, etc.) Weight at birth: Complications during delivery? Y or N If Yes, please explain: Did this child require admission into the neonatal intensive care unit (NICU)? Y or N If Yes, how long and why? This child has met majority of his/her developmental milestones in a timely manner: Yes No Age he/she began: Crawling Walking Talking - single words 2+ word sentences This child s overall development is occurring: Slowly Normally Quickly Medical History Heart problems Y or N If Yes, please explain: Lung problems Y or N If Yes, please explain: Eye problems Y or N If Yes, please explain: Ear infections/tubes Y or N If Yes, please explain: Speech problems Y or N If Yes, please explain: Sensory problems Y or N If Yes, please explain: Broken bone(s) Y or N If Yes, please explain: Surgery Y or N If Yes, please explain: Allergies Y or N If Yes, please explain: Asthma Y or N If Yes, please explain: Seizures Y or N If Yes, please explain: Head injury/concussion/unconsciousness Y or N If Yes, please explain: Other: Are his/her immunizations current? Y or N If No, please explain: If your child has been/is on psychoactive medication, how old was he/she when it was first prescribed? By whom? For what? Current regularly used medications, including prescriptions, over-the-counters, herbals, and/or essential oils: Medication Dosage Times/Day For what reason JCCTA Page 2
3 Additional prescription medications used in the past: Medication For what reason Reason for discontinuation Academic History Current grade (or most recently completed)? School and ISD? Has this child ever repeated a grade? Y or N If Yes, what grade(s)? Who initiated retention? Why? Has he/she ever received RtI, 504, Special Education (IEP), or other intervention services? Y or N If Yes, how was he/she qualified and what service(s) did he/she receive? Is this child currently experiencing academic problems? Y or N If Yes, please explain: Please describe what kind of grades/marks he/she generally achieves in school: Has this child ever received formal testing through the school, apart from standardized testing? Y or N If Yes, please explain: Does this child exhibit behavioral problems at school? Y or N If Yes, please explain: Has he/she ever received detention, in school suspension, out of school suspension, or expulsion? Y or N If Yes, please explain: At what level do you estimate your child s intelligence? below average average above average Mental and Emotional History SYMPTOM Y N ST NOTES Attention problems Hyperactivity Impulsivity Academic problems Failing classes Communication problems Memory problems Anger Anxiety Negative self-talk Low self-esteem Irritability Low frustration tolerance Threatens to harm self Acts of self-harm (i.e., cutting) Suicidal ideation Elevated moods/mania Mood swings Aggressive - verbal and/or physical Defiance/intentional breaking of rules Temper tantrums JCCTA Page 3
4 Lying Stealing Disrespectful toward adults Threatens to harm others Toileting accidents/bedwetting Poor hygiene Nightmares/terrors Hears things that are not there Sees things that are not there Sleep difficulties Difficulty making/keeping friends Poor social skills Lacks empathy Other difficulties Please provide elaboration on any specific symptom(s) which warrants very direct intervention: Has this child been abused? Y or N (circle one and all that may apply) Sexually Verbally Physically Mentally Emotionally Other: When? Who was the abuser? Has this child experienced any other traumatic event(s)? Y or N If Yes, please explain: Have there been any significant deaths or losses in the family? Y or N If Yes, please explain: Has this child ever participated in therapy? Y or N Undergone formal testing? Y or N With whom? When? Was a diagnosis assigned? Y or N. If yes, what? Was the previous treatment beneficial? Y or N or Somewhat Please explain: Has your child ever been admitted for inpatient psychiatric care? Y or N If Yes, please provide details regarding admission dates, precipitating events, treatment received, perceived benefit, etc. Parenting D0 you believe you do an effective job parenting this child? Y or N Please explain: What discipline technique do you use that is most effective? Least effective: Do adults/caregivers in this child s life agree on how to discipline him/her? Y or N Is this a problem for you, this child, and/or your family? Y or N Please explain: Strengths and Weaknesses What do you think are this child s biggest strengths? JCCTA Page 4
5 3. What do you think are this child s biggest personal weaknesses/limitations? Please provide any additional information you think we need to know. Signature and Date JCCTA Page 5
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