Name *

First Name

Last Name

Name of child *

First Name

Last Name

Phone *

(###)

###

####

Date *

Please enter today's date

MM

DD

YYYY

Presenting Problems and Concerns *

Please check all your child's behaviors and symptoms that you consider problematic.

Distractibility

Hyperactivity

Impulsivity

Boredom

Poor memory/confusion

Sadness/depression

Hopelessness

Thoughts of death

Self-harm behaviors

Crying spells

Loneliness

Low self-worth

Fatigue

Recurring, disturbing memories

Change in appetite

Withdrawl from people

Anxiety/worry

Panic attacks

Fear away from home

Social discomfort

Phobias

Obsessive thoughts

Compulsive behavior

Racing thoughts

Wide mood swings

Suspicion/paranoia

Hearing voices

Visual hallucinations

Defiance

Aggression/fights

Homicidal thoughts

Frequent arguments

Irritability/anger

Peer/sibling conflict

Stealing

Destroys property

Swearing

Curfew violations

Lying

Manipulative behavior

No/few friends

Eating problems

Sleep problems

Nightmares

Toileting problems

Firesetting

Work/school problems

Legal problems

Sexual behavior

Computer addiction

Alcohol/drug use

Lack of motivation

Are your child's problems affecting any of the following? *

Please check all that apply.

Handling everyday tasks

Recreational activities

Self-esteem

Work/School

Relationships

Housing

Hygiene

Legal matters

Health

Finances

Has your child ever had thoughts, made statements, or attempted to hurt him/herself? *

Yes

No

Has your child ever had thoughts, made statements, or attempts to hurt someone else? *

Yes

No

Has your child recently been physically hurt or threatened by someone else?? *

Yes

No

Has your child gambled in the past 6 months? *

If yes, please let us know the following:

Yes

No

Has your child ever felt the need to bet more and more money?

Yes

No

Has your child ever lied to people about how much money your child has gambled?

Yes

No

Mother

First Name

Last Name

Father

First Name

Last Name

Stepmother

First Name

Last Name

Stepfather

First Name

Last Name

Siblings

First Name

Last Name

Other relatives

First Name

Last Name

Please check if your child has experience any of the following: *

Please select all that applies:

Emotional abuse

Sexual abuse

Physical abuse

Parent substance abuse

Teen pregnancy

Neglect

Violence in the home

Crime victim

Parent illness

Place a child for adoption

Lived in a foster home

Multiple family moves

Homelessness

Loss of a loved one

Financial problems

Name *

Name of child

First Name

Last Name

Outpatient Counseling *

Yes

No

Date of treatment

MM

DD

YYYY

Medication (mental health)

Yes

No

Date of treatment:

MM

DD

YYYY

Psychiatric Hospitalization *

Yes

No

Date of treatment:

MM

DD

YYYY

Drug/Alcohol Treatment *

Yes

No

Date of treatment:

MM

DD

YYYY

Self-help/Support Groups *

Yes

No

Date of treatment:

MM

DD

YYYY

Has your child had any of the following difficulties at school? *

Please select all that apply.

Suspension

Poor grades

Gang influence

Incomplete homework

Teased or picked on

Learning problems

Speech problems

Referrals or detention

Attendance problems

None of the above

Name *

Name of child

First Name

Last Name

Please describe your child's social support network: *

Please select all that apply.

Family

Friends

Community Group

Neighbors

Students

Religious/Spiritual Center

Co-workers

Support/Help Group

Name *

Name of child

First Name

Last Name

Date of last physical exam: *

MM

DD

YYYY

Has your child experienced any of the following medical conditions in his/her lifetime? *

Please select all that apply:

Allergies

Chronic pain

Dizziness/fainting

High Fevers

Misscarriage

Asthma

Surgery

Meningitis

Diabetes

Abortion

Headache

Serious accident

Seizures

Hearing problems

Sleep disorder

Stomach aches

Head injury

Vision problems

Ear infection

Sexually transmitted disease