Please describe cultural/ethnic identification and/or religious/spiritual affiliation and their role in family life. For what Problem(s) are you seeking help? General Behavior of Client/Child Patient(check all that apply): Friendly, Outgoing Shy Easygoing, Calm Irritable Hardworking Lazy Prefers Company Prefers to be Alone Optimistic Pessimistic Caring Uncaring Cooperative Stubborn Confident Expects Failure Sharing Selfish Respectful Defiant Takes Risks Cautious Generally Happy Generally Unhappy Notes: Problem Areas (check all that apply): Thoughts Worries Fears Obsessive Compulsive Odd Disturbing Behavior Compulsive Repetitive Odd Messy Inattentive Short Attention Span Distractible
Impulsive Hyperactive Accident Prone Runs Away From Home Tantrums, Angry Outbursts Bullies Argues Defiant, Oppositional Fights Lies Steals Legal Problems Destroys Property Sets Fires Cruel to Animals Reckless, Careless Disruptive Notes: Mood Mood Swings Sadness Depression Crying Spells Irritable Withdrawn Boredom Nervousness Anxiety Notes: Appetite Decrease Increase Weight Changes Additional Information: Sleep Nightmares Night Terrors Insomnia Sleepwalking Will Not Sleep Alone Additional Information: School
Missing School Due to Illness Skipping Classes/School Learning Problems Speech Problems Poor School Work Additional Information: Developmental History Mother’s pregnancy was (circle one): Normal Complicated Please explain: Medication use during pregnancy? Please describe. Client’s condition at birth (circle one): Normal Abnormal Please explain: Birth Weight: As an infant, client was (check all that apply): Easy to Manage Alert/Responsive Irritable A Poor Eater Demanding A Poor Sleeper Additional Information: At what age did the client: Sit up unassisted Crawl Walk without support Toilet trained Use words Use sentences Toilet training was (circle one): Easy Difficult Notes: Significant Life Events Please indicate any important events in the client’s life (check all that apply): Change of residence Change of schools Change of custody Marital conflict Parents separated
Parents divorced Parental visitation problems Post-divorce parental problems Parent(s) remarried Step-parent problems Sibling birth Step-sibling problems Family economic problems Family job problems Other family problems Rejection by family members Suffered/Witnessed significant accident/injury Other severe fright or trauma Death of family member Death of friend Death of pet Please describe. School History Current School: Street Address: City: State: Zip Code: Phone: ( ) Current Grade Level: Has the client repeated a grade? Please explain. Has the client skipped a grade? Please explain. Please describe the client’s academic grades. Is or has the client even been involved in special education? Please explain. Does the student have an IEP? yes no Is the student on a 504 plan? yes no Has there ever been any indication of a learning problem? Please describe. Please describe the client’s study habits. Please describe the client’s behavior in school. Has the client ever been suspended or expelled from school? Please explain.
Have you ever been involved in criminal or civil proceedings? (circle one) Yes No If yes, please explain. (check all that apply): Suspended/Revoked driver’s license Conviction for misdemeanor Conviction for felony DUI/DWI Shoplifting Assault/Battery Property Damage Other Please explain. Have you ever been charged or arrested for any offense involving drugs or alcohol? (circle one) Yes No If yes, please explain. Are you currently on probation? (circle one) Yes No If yes, please explain the reason and terms of probation. Is there a family history of legal problems? (circle one) Yes No If yes, please explain. Notes: Medical History Please describe the client’s current physical health. Is the client currently taking medication? (circle one) Yes No Please describe. Has the client have allergies? (circle one) Yes No If yes, please explain. Has the client ever had a serious accident or injury? (circle one) Yes No If yes, please explain. Has the client ever been medically hospitalized? (circle one) Yes No If yes, please explain.