Child and Family Information

Child’s Name ______________________ Age ______ Date of Birth _______________

Today’s Date ______________________ Referred by __________________________

Father’s Name _______________________Age_______ Education ___________yrs

Type of Employment ______________________________

Approximate Annual Income* $________________________

Mother’s Name ______________________Age________ Education ___________yrs

Type of Employment ______________________________

Approximate Annual Income* $________________________

* Optional, but helpful in understanding your child’s overall needs-Range is ok.

Is Child adopted? __Yes ___No If yes, age when adopted ____________________

Parents' Marital Status: Check as many as apply

__ Mother and Father of child married to each other

__ Parents of child never married to each other

__ Parent separated from other parent

__ Parent divorced from other parent Year?____

__ Parent presently married to person other than child’s parent

__ Parent presently living with partner other than child’s parent

Other ___________________________________________

Please list all other family members in home(s) of child:

Name                                                                               Age                     Relationship

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

_________________________________________ ___________ _____________________

Child’s School __________________________________________________________

Teacher’s Name(s)________________________________________________________

Is Child getting special educational services? __ Yes  __No

If so, what type?__________________________________________________________

Child’s Physician:_____________________________________________________________

Physician’s Address _______________________________________Phone ________________

Date of Child’s last physican visit (approximate if not known): __________________________

Child's Health History

At any time has your child had the following:

Never

Past

Present

Item
      Problems during Pregnancy What?
      Difficulty surrounding birth What?
      Accidental poisoning or lead poisoning
      Allergies List:
      Appetite problems ___overeating ___undereating
      Asthma
      Broken bones
      Chicken pox or other common childhood illnesses
      Chronic ear infections ___tubes in ears
      Diabetes, arthritis, or other chronic illness __________________
      Epilepsy or seizure disorder
      Eye or vision problems
      Fine motor/handwriting problems
      Gross motor difficulties, clumsiness
      Head injury ___concussion ___with loss of consciousness
      Hearing difficulties
      Heart or blood pressure problems
      High fevers (over 103 degrees)
      Lengthy hospitalization When and reason?
      Seizures On Medication ?_______
      Severe cuts requiring stitches
      Sleep problems ___falling asleep ___staying asleep
Snoring/Apnea
      Soiling problems
      Speech or language problems
      Surgery For what?
      Wetting problems  ___bedtime  ___daytime
      Other (describe)_______________________________________

List any medications that the child is on now:
Medication Purpose How much When given Date Began
         
         
         
         

Other medications used in the past to help with mood or behavior

( Give approximate age of child or date):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

 

Significant Life Changes and Stressors

Mark any of these events that have happened to the child or the child’s family in the past year:

 ___Loss of acceptance by peers

___Parent’s separation or divorce

___Parent(s) married

___Parent involved in new relationship

___Major illness of family member

___Major change in family income or financial distress

___Parent job change

___Unwed pregnancy

___School failure

___Involvement with drugs or alcohol

___Death of a close friend or family member

___Hospitalization of child or family member

___Jail sentence of parent or family member Who?__________________________________

___Moved

___Any member of family involved in legal system What?____________________________

___Other _______________________________________________

Parent/Caretaker Level of Stress is:

                  ___Extremely High

                 ___ Moderately to Severely High

                ___ Mild to Moderately

                ___Low to Moderate

                ___Very Low

Biological Emotional and Behavioral History

Are there any biologically related relatives (aunts, uncles, grandparents, cousins, parents) who have (even without being formally diagnosed) a history of:
Type of Problem Whom (mother, maternal aunt, paternal grandfather, etc)
Depression  
Alcoholism  
Mental Illness  
Mood Disorders  
Obsessions/Compulsions  
Suicide Completed  
Suicide Attempts  
Impulse Control  
Chronic Irritability  
Explosive Rages  
Chronic Drug Usage  
Attention Deficit Disorder or hyperactivity  
Domestic Violence  
Learning Disabilities  
School Failure  
Other  

Behavior, Mood and Problem Rating

Rate your child using the following scale:

0 not a problem 1 slight problem 2 moderate problem 3 severe problem
0 1 2 3 Depressed, looks or feels sad
0 1 2 3 Easily tearful
0 1 2 3 Threatens to hurt self
0 1 2 3 Wishes were dead
0 1 2 3 Worried or anxious
0 1 2 3 Angry, often irritable
0 1 2 3 Mood swings
0 1 2 3 Difficulty being away from parent
0 1 2 3 Hyperactive, as if driven by a motor
0 1 2 3 Has trouble focusing, paying attention
0 1 2 3 Defiant, will not cooperate
0 1 2 3 Misbehavior in public settings
0 1 2 3 Temper tantrums
0 1 2 3 Appears in a fog or not tuned in
0 1 2 3 Day dreams a lot 		0 1 2 3 Running away
0 1 2 3 Lying
0 1 2 3 Stealing
0 1 2 3 Tiredness, fatigue, lack of energy
0 1 2 3 Sexual behavior
0 1 2 3 Drug or alcohol abuse
0 1 2 3 Tobacco use
0 1 2 3 School conduct problems
0 1 2 3 Excessive absences, truancy from school
0 1 2 3 Obsessions, compulsions or unwanted       repeated, senseless acts
0 1 2 3 Legal problems
0 1 2 3 On probation past or present
0 1 2 3 Arguing and verbal fighting
0 1 2 3 Physical fighting and assault

Has there been previous counseling? Yes No If yes, for what reason?

 

 

About how many visits? ______________During what time period?_______________

What was helpful or not helpful?

 

 

 

 

Any other information that might help us understand your child and your family better:

 

 

 

 

 

 

Person filling out form: ________________________________

                                                                           Signature

Thanks so much for taking the time to fill out this form.

 

WSChhx10-2004