Child’s Name:
Date of Birth:
Age:
Gender:
Preferred Pronouns:
Reason(s) for bringing your child to treatment:
Briefly describe your goals for your child’s therapy:
Other:
Other:
Other:
Visitation Schedule
What is the custody arrangement regarding physical/mental health care?:
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School
Name:
Age:
Relationship:
Occupation/School:
Name:
Age:
Relationship:
Occupation/School:
List any family history of mental illness or substance abuse (ex: depression, alcoholism, etc):
How is your child disciplined? List method and frequency of use:
How does your child handle anger?
What do you view as your child’s strengths/weaknesses?
What are your child’s hobbies/interests?
What are your child’s responsibilities at home?
Other:
School Name:
Location:
Grade:
Specify
Drugs (specify):
List any birth complications (premature, jaundice, C-section, etc.):
Parental stress (describe):
Date of last PCP visit:
PCP Name:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Medication:
Strength/Dosage:
Comment
Allergen:
Reaction:
Allergen:
New Field:
Allergen:
Reaction:
Allergen:
Reaction:
Allergen:
Reaction:
List any current or past medical conditions:
If yes, please list provider, reason for treatment, and dates:
If yes, please list provider, reason for treatment, and dates:
Drugs (specify):
Specify:
Specify:
Specify:
Specify:
Other:
How many times has the child moved homes?
Anger
Anxiety
Acts out sexually
Low impulse control
Bed wetting
Low self-esteem
Conduct problems
Lying
Controlling defecation
Masturbates excessively
Day wetting
New Field:
Depression
Obsesses
Defiance
Peer problems
Dissociates
Phobias
Drug or alcohol use
Plays out sexual themes
Headaches/stomachaches
Plays out violent themes
Homicidal thoughts/actions
Running away
Hyperactivity
New Field:
Hyper vigilance
Sleeplessness
Impaired conscience
Stealing
New Field:
Tantrums
Lack of empathy
Unusual sexual knowledge
Lack of motivation
New Field:
Lethargy
Please add any further information you feel the therapist should know:
Parent/Guardian Name PRINTED
DATE
