Dr. John Carosso, Psy.D Psychologist Autism Center of Pittsburgh
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- Laureen Cannon
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1 Dr. John Carosso, Psy.D Psychologist Autism Center of Pittsburgh Evaluation Date: Client Information Child s Name: Date of Birth: Age: Male Female Eye Color Ethnicity: Insurance: Primary _ ID # Grp # Card Holder Name _ Card Holder Date of Birth: _ (If other than child) Secondary Insurance (Medical Assistance) 10 Digit # Social Security #: Family Information Address: County: Phone Number: Alternative # Address: Please list all those who live in the home with child: Name Age Relationship Parent Occupation Mother: Family s Religious Affiliation: Father: Parent Marital Status (please circle): Married; Divorced; Separated; Single; Never Married; Re- Married Any siblings outside of the home: School Information School: School District: Grade: Special Education: No Yes: Type: Learning Support Emotional Support
2 Page 2 of 5 Heath / Medication / Mental Health Any previous diagnoses?: No Medications: Name Yes. Please specify: Dose Who prescribes the medication: Child s Pediatrician: Pediatricians Phone # Medical Conditions Allergies No Yes: Type- Asthma No Yes Seizures No Yes Hearing deficits (hearing aide?) No Yes Vision deficits (glasses?) No Yes Serious medical conditions? No Yes Services Any history of mental health services? No Yes If yes, please specify type (outpatient counseling, wraparound ): Any current mental health services? No Yes If yes, please specify type (outpatient counseling, wraparound ): The agency s name providing the services: You were referred to Dr. Carosso by: Television program (Wed s 7:30 PM PCNC); Commercial; Pediatrician; Casemanager; Internet Ad; Newspaper Ad; Other, please specify: CURRENT CONCERNS (Please check- mark those that apply) Family Instability / Trauma / Abuse Physical Abuse Witness of domestic violence Foster care Neglect Parent Incarceration Sexual Abuse Witness of parental substance abuse Out of home placement Children- Youth services involvement Signs of Autism: Speech/Language difficulties (limited vocabulary; talks in short phrases...) Not wanting to socialize
3 Page 3 of 5 Not knowing how to socialize Poor eye contact Lack of imagination/play skills (not knowing how to play) Odd Behaviors: hand- flapping rocking bouncing/hopping echoing others (repeating) toe- walking lining- up of objects spinning objects or themselves fascination with moving objects (fans, trains ) obsessing on topics repeating words and phrases from videos (scripting) immediately repeating words of others (echoing others) Difficulty with changes in routine or unexpected events Extra sensitive to clothing, sound, food, textures, light Seems to seek sensory stimulation by bumping into things, wanting firm hugs Restricted food preferences Behavioral Problems Defiance Back- talk Verbal Aggression Attention problems Hyperactivity Difficult community behavior Tantrums Ignoring of direction Physical aggression Destruction of property Impulsivity Deficient grooming and hygiene Tough time doing homework Emotional Problems Appears depressed Irritability Obsessive thoughts Sleep problems Self- Injurious behavior Social Problems Difficulty establishing friendships Difficulty maintaining friendships Arguments with peers Physical confrontations with peers School problems Underachievement Behavior problems in school After- School Detentions Anxiety Compulsions (doing things over and over) Low self- esteem Talk of wanting hurt self or not be alive Psychiatric hospitalization Alienated by peers Withdraws from peers Social phobia (extreme fear of social situations) School refusal Suspensions Threat of expulsion
4 Page 4 of 5 Lunch/Recess Detentions Problems reading Problems writing Does not turn- in homework Does not bring homework home Food Issues Lack of appetite Over- eating Bingeing (eating large amts of food all at once) Purging Low calorie intake Poor grades Problems with math Leaves homework at home Being bullied Finicky Excessive time to eat meals Putting too much food in mouth at once Choking/Gagging Can t sit through a meal Delinquency Problems with the police Running away from home Alcohol use Marijuana use Cigarette use Stealing from home/community (stores) Probation Birth and Early Development Any complications during pregnancy/delivery: No Yes If Yes, please explain: Any substances used during the pregnancy? Yes No Full- term: Yes / No Birth Wt: Born Healthy: Yes / No Mom and Child discharged together: Yes / No Infant temperament: Calm and Pleasant; Fussy Any serious illnesses during infancy?: Yes No Developmental Milestones Walked independently by one year of age: Yes / No Began expressing words and short phrases by two years of age: Yes / No Toilet trained on time: Yes / No / N/A Urination: Yes / No Bowel Movements: Yes / No
5 Page 5 of 5 Any history of parental substance abuse? Yes No Any history of domestic violence? Yes No History of child experiencing any trauma or abuse (N / Y) Specify: History of child being psychiatrically hospitalized (N / Y) Your child was how old when you first began to have concerns about his/her behavior: What were your first concerns? STRENGTHS / SUPPORTS Please list a number of things your child enjoys doing: Please list some positive things about your child (examples: athletic, can be a good helper at times, good sense of humor, intelligent, inquisitive, friendly ) Please list some family strengths and supports (examples: extended family including grandparents, church family, family friends, Casemanager, Counselor, Big Brother or Sister, Boy or Girl Scouts, other community agencies )
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