INSTRUCTIONS: It is very important that you answer all the questions as completely and as detailed as possible. If you do not know the answer to a question just put a question mark (?). If the question does not apply to your child just put NA for not appropriate. Your help in this is much appreciated.
Child's Name: _______________________________ Birth-date:____________ Age:______
Child's Address: _________________________________________ Zip Code: __________
Parent's Names: ____________________________________________________________
Parent's Home Phone #:______________________ Work Phones:_____________________
Child's School:_____________________ Address:_________________________________
School's Phone #:___________Grade:_____ Main Teacher: __________________________
Brothers' Names and Ages: ___________________________________________________
Sisters' Names and Ages: _____________________________________________________
In 3 or 4 sentences what do you feel is your child's present problem?
When did the problem begin? When did you first notice a change in your child's behavior? How long has your child been having behavior and/or emotional problems?
What promoted you to seek help at this time?
Has your child received previous psychiatric, psychological, or counseling services?_____ If yes, with whom?___________________________________________ When:_______________ Therapist's Address:______________________________ Zip: ________ Phone:__________
Name of Child's Physician?___________________________ When was last visit? ________
Medications your child is currently taking:_________________________________________
Medications your child has taken in the past: ______________________________________
Please circle any of the following that apply to your child now and indicate for how long it has been a problem:
Pregnancy and Birth: If adopted, indicate at what age ____________
1. Parents ages when child was born: Mom _____________ Dad _________
2. Was your pregnancy planned? Yes______ No_______
3. Was your pregnancy with this child normal? Yes_____ No_____
4. Was your pregnancy full-term? Yes ______ No _____
5. Were you free of illnesses during your pregnancy? Yes ______ No _____
6. Free of emotional strain during your pregnancy? Yes ______ No _____
7. Free of morning sickness? Yes ______ No _____
8. Were you pleased to learn you were pregnant? Yes ______ No _____
9. Did the baby come on time? Yes ______ No _____
10. Did the baby come out head first? Yes ______ No _____
11. Did the baby begin breathing without difficulty? Yes ______ No _____
12. Was the baby well the first week? Yes ______ No _____
13. Were you free of blood pressure problems? Yes ______ No _____
14. Any other difficulties during pregnancy? Yes ______ No _____
If yes, please state what the difficulties were: ____________________________________
15. Did either parent use substances (e.g., alcohol, drugs) prior to and/or during pregnancy?
Yes _____ No ______ If yes, who ___________________________________________
16. Any problems during delivery? Yes ______ No _____
If yes, please state what the problems were? ____________________________________
17. Any problems after delivery? Yes _____ No _____
If yes, please state what the problems were? ____________________________________
18. Was the cord around the baby's neck? Yes ______ No _____
19. Was an incubator or oxygen needed for the baby? Yes ______ No _____
20. Did you ever fall during your pregnancy? Yes ______ No _____
21. Length of labor______________ Was it induced? Yes ______ No _____
22. Birth weight_______________ Birth length ________________
1. Who was the primary caretaker? __________________________________________
2. Was the child during the first year: irritable ____ fussy ____ listless ____
normally active ____ very active ____ quiet ____?
3. Did the baby ever experience colic? Yes _____ No _____
4. Does your child ever experience pain or stomachaches? Yes _____ No _____
5. Was there any vomiting during the first year? Yes _____ No _____
6. Any problems with feedings during first 3 months of life? Yes _____ No _____
7. Any problems establishing sleep habits during the first year? Yes _____ No _____
8. Did you breast feed? Yes _____ No _____ If yes, how long? _______________________
9. Were the infant's bowel movements alright? Yes _____ No _____
10. Has your child's appetite usually been good?Yes _____ No _____
1. Has your child ever been hospitalized? Yes _____ No _____
If yes, what for? ______________________________________________________
2. Has your child ever had a fever over 104? Yes _____ No _____
3. Were there ever any convulsions or seizures? Yes _____ No _____
4. Has the child ever been knocked unconscious? Yes _____ No _____
5. Has the child had normal urination? Yes _____ No _____
6. Has the child's hearing been checked? Yes _____ No _____
7. Has the eyesight been checked? Yes _____ No _____
8. Has the child had a physical recently? Yes _____ No _____
9. Please circle any of the following that your child has had and indicate your child's age (or ages) at the time:
At what age did your child sit alone? _____ stand alone? _____ walk? _____
say first word? _____ speak first sentences? _____ cut first teeth? _____
become bowel trained? _____ ride a tricycle? _____ stop taking naps? _____
1. Please circle the number that best applies to your child:
a. activity level:
b. Rhythmicity: predictability of habits and patterns:
c. approach-withdrawal: response style to new situations or people
d. Adaptability: reactions to changes
e. Threshold level: responses to noise, bright lights, etc.
f. Intensity of Reactions: how disappointment and pleasure shown
g. Quality of Mood:
1. Please describe any incidents of sexual, physical, or emotional abuse:
2. Please describe any accidents that your child has been involved in:
3. Has your child lost a family member or friend?
1. Describe the history of the child's relations with his or her:
c. sibling(s) and extended family
In this section, please list what grades your child made in Kindergarten through High School as appropriate. Also please describe your child's behavior in the classroom and how your child got along with the other children at school.
Class ---Grades made (A,B,C,D,F)----Class room behavior and peer relations
Who took your child to his or her first day of school?
How did your child respond to his or her first day of school?
Describe your child's academic strengths and weaknesses:
Has your child ever repeated a grade? Which grade? How did your child respond academically? How did your child respond emotionally?
Has your child ever had psycho-educational testing? Where? By whom? For what purpose?
Has your child ever been in special education? Where? How long?
1. Current Martial Status _______________________________
2. Martial History:
a. How long have you been married? _____________________
b. Have either of the child's parents been divorced? ______Who? ________________
How old was your child when the divorce occurred?____________
c. Describe your current marriage relationship by circling the following that apply:
3. Describe both parents education:
4. Work history:
5. Parents interests, hobbies, and activities:
6. Medical: Please describe any parents problems in any of the following.
e. Problems with:
7. Describe any previous or current psychological treatment for either of the parents:
8. Describe any financial problems:
9. Parent's legal history:
10. Parent's problems with relatives or friends:
11. Parent's occupational/employment problems:
12. Does any other child in the family have behavior or emotional problems?_____ If yes, please describe:
13. Please indicate which family members have experienced any of the following. Include parents, maternal grandparents, paternal grandparents, aunts, uncles, cousins, and siblings.
1. Please describe any problems in managing your child's behavior:
2. How much time do you spend with your child per day?
3. What activities do you do with your child per day?
4. What activities do you do with your child per week?
5. Please describe the discipline strategies that you have used to manage your child's behavior problems:
6. Have your child's behavior problems had a negative emotional impact on you and/or your spouse?_____ If so, please describe?
7. What are your child's strengths? What is he or she good at?
8. What are your child's weaknesses?
9. What do you think has caused your child's problems?
10. What would you like to see change about your child's problems?
11. What do you see your role will be in your child's process of change?
12. What do you or your spouse want to change as parents or persons?
Please circle the following drugs used and when started and for how long:
Marijuana, (pot, THC, hashish)
Amphetamines, (speed, uppers, diet pills)
Cocaine LSD PCP Opiates
Is your child sexually active? Yes _____ No _____ Not sure _____ If yes, please describe how you know and how long has your child been sexually active.
Does your child attend church? Yes _____ No _____ If yes, please tell which church and describe your child's attitude and behavior toward church.