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Laura A. Guli, Ph.D., LSSP
Licensed Psychologist
Licensed Specialist in School Psychology
3625 Manchaca Rd., Suite 202
Austin, TX 78704
(512) 522-4093
CHILD AND ADOLESCENT BEHAVIORAL HEALTH HISTORY
Child/Adolescent’s Name: School: Age: DOB:
Your Name: Relationship to child: Address: ZIP
Home Phone: Work Phone: Cell Phone: Email:
Please indicate any other professionals who are currently involved with the child/adolescent:
Primary Care Physician: Phone:
Therapist/Counselor:Phone:
Psychiatrist:Phone:
Other(s): Phone(s):
How did you hear about Dr. Laura Guli?
Identify your child/teen’s strengths and the things that you like best about him/her:
What are the current concerns? Please list in order of importance:
1.
2.
3.
How has the family attempted to deal with these concerns?
What do you hope to learn or accomplish as a result of this evaluation/counseling?
SOCIAL/BEHAVIORAL HISTORY
Who are the primary caregivers of this child/adolescent?
Name(s) of the individual(s)or couple(s) / City/State / Relationship to Child
(biological, step, foster, adoptive, or other) / Marital Status/
Years / Employment Status and
Job Position / # Work Hours/Week
Who is/are the child/teen’s legal guardian(s)? What is the current custody arrangement?
What are the strengths and resources of the family or families?
What are the struggles of this family?
With whom does this child currently live? List the names of all people who reside in the home and rate the quality of their relationship with the child/teen (1 = very poor, 2 = poor, 3 = average, 4 = good, 5 = excellent):
LIST PEOPLE IN HOME: / AGE / RELATIONSHIP TO CHILD / RATING (1-5) / COMMENTSHow easily does this child/teen make friends?
□More difficult than average□Average□Easier than average□Don’t know
What types of changes or stressful events has the child/teen experienced?
EVENT / DATE / DETAILSChange in residence
Divorce, separation, remarriage of parent
Job change of parent
Death or loss of family member/friend
Serious illness
Other:
Other:
MEDICAL HISTORY
Date of your child/teen’s last physical:Describe the results:
How would you describe this child/teen’s overall health?
□ Very good □ Good □ Fair □ Poor □ Very poor
Does he or she have a disability? □ No □ Yes (provide details):
How would describe your child’s current sleep pattern?
□ Sleeps very little□ Sleeps average amount □ Sleeps much more than average
Describe anything unusual about your child/teen’s sleep pattern:
How would describe your child/teen’s current eating pattern?
□ Eats very little□ Eats an average amount □ Overeats
Describe anything unusual about your child/teen’s appetite or eating habits:
Please describe any major or recurrent health/medical issues (e.g., seizures, loss of consciousness, major surgery, diabetes):
Please list any medications that your child/teen has taken for treatment of a medical, health, or emotional/behavioral condition. Exclude medications for routine illnesses (e.g., colds, flu, strep throat).
NAME OF MEDICATION / REASON PRESCRIBED / AGE(S) OF CHILD OR DATES WHEN MED STARTED / ENDED / REASON IT WAS DISCONTINUED/
/
/
/
Has he or she had any emergency room visits for emotional or behavioral problems?
□ No□ Yes (provide details):
If your child/teen has used drugs or alcohol, or you suspect that he / she has, please estimate the frequency for each substance using the following scale:
0 = Not at all1 = Rarely2 = Sometimes 3 = Many times
SUBSTANCE USE HISTORY / Past month / In generalCigarettes
Alcohol
Marijuana
Huffing or sniffing
Cocaine
Amphetamines / methamphetamines
Opiates (codeine, heroin, etc.)
Hallucinogens (LSD, mushrooms, etc.)
Prescription drugs taken other than as intended by physician
Over-the-counter drugs taken other than as intended by adult caregiver
Other (please specify):
Please list any relevant family history of mental health issues, chemical/alcohol problems:
EDUCATIONAL HISTORY
Describe your child/teen’s strengths in school:
Describe what your child/teen struggles with in school:
Does your child receive 504 Program services? □ No □ Yes (provide details):
Does your child receive special education services? □ No □ Yes (provide details):
Previous educational interventions/treatment attempts:
Have any disciplinary actions been taken at school?
□No□Yes (provide details):
Has your child/teen ever repeated any grades?
□No□Yes (provide details):
SYMPTOM CHECKLISTS
Read each symptom below and decide how much each one applies to your child/adolescent:
0 = Not at all1 = Rarely2 = Sometimes 3 = Many times/Very Often
INATTENTIVENESS / Past month / In generalFail to give close attention to details or make careless mistakes in schoolwork, work, activities
Difficulty sustaining attention in tasks or play activities
Difficulty listening when spoken to directly
Does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (behavior is not due to poor comprehension of instructions or defiance)
Difficulty organizing tasks and activities
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school or homework)
Loses things necessary for tasks or activities (such as toys, school assignments, pencils, books, or tools)
Easily distracted by things that are not relevant to the task at hand
Forgetful in daily activities
HYPERACTIVITY/IMPULSIVITY / Past month / In general
Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in which remaining seated is expected (such as meal time, riding in a car, etc.)
Runs about or climbs excessively in situations in which it is inappropriate, or excessive restlessness given age
Difficulty playing or engaging in leisure activities quietly
Is “on the go” or acts as if “driven by a motor”
Talks excessively
Blurts out answers before questions have been completed
Difficulty awaiting turn
Interrupts or intrudes on others
0 = Not at all1 = Rarely2 = Sometimes 3 = Many times/Very Often
DISRUPTIVE BEHAVIORS / Past month / In generalBully, threaten, or intimidate others
Initiate physical fights
Have used a weapon that can cause harm
Have been physically cruel to people or animals
Have stolen while confronting a victim
Have forced someone into a sexual activity
Have deliberately engaged in fire setting
Swear or use obscene language
Have deliberately destroyed others’ property
Lie to obtain favors or avoid obligations
Have stolen without confrontation (such as shoplifting, stealing at home, etc.)
Truancy
Have broken into someone else’s house, building, or car
Loses temper
Argue with others
Actively defy or refuses requests or rules from authority figures
Deliberately do things that annoy other people
Blame others for own mistakes
Are touchy or easily annoyed by others
Are angry or resentful
Are spiteful or vindictive
DEPRESSED MOOD / Past month / In general
Depressed or irritable mood most of the day, nearly every day
Diminished interest or pleasure in all or almost all activities, most of day, nearly every day
Significant weight loss or weight gain, decrease or increase in appetite nearly every day
Difficulty sleeping or oversleeping nearly every day
Fatigue or loss of energy nearly every day
Feelings of worthlessness or excessive or inappropriate guilt nearly every day
Explosive temper or marked mood swings with minimal provocation
Agitation or lethargy
Decreased concentration
Recurrent thoughts of death
Suicidal thinking, threats, plan, or attempt
ELEVATED MOOD / Past month / In general
Periods of excited, elevated, or irritable mood (i.e., rages or extreme hyperactivity)
Periods of abnormal or unrealistic, inflated self-esteem
Periods of decreased need for sleep (i.e., feels rested after 3 hours of sleep)
More talkative than usual or pressure to keep talking
Racing thoughts
Distractibility
Periods of high risk activity (unrestrained buying sprees, reckless driving, promiscuous sexual activity, drug or alcohol binges, etc.)
0 = Not at all1 = Rarely2 = Sometimes 3 = Many times/Very Often
ANXIETY / Past month / In generalExcessive anxiety or worry
Recurrent distressing recollections or dreams of a traumatic event
Brief periods of intense fear or discomfort, characterized by accelerated heart rate, sweating, trembling, shortness or breath, dizziness, or fear of losing control
Excessive anxiety concerning separation from home or major attachment figures
Persistent fear of one or more social or performance situations in which the person is exposed in unfamiliar people or to possible scrutiny by others
Recurrent and persistent thoughts, impulses, or images that are experienced as intrusive and inappropriate, and that cause anxiety or distress
Repetitive behaviors (such as handwashing, ordering, checking, etc.) or mental acts (such as praying, counting, repeating words silently, etc.) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
EATING DISORDER BEHAVIORS / Past month / In general
Nutritional restriction or dieting
Fear of weight gain
Binge eating
Self-inducted vomiting
Laxative or diuretic use
Excessive exercise
OTHER CONCERNS OR SYMPTOMS / Past month / In general
Motor or vocal tics
Odd postures
Little or no interest in peers
Starts or ends social interactions inappropriately
Excessive reaction to changes in routine
Delayed or abnormal speech
Bizarre ideas
Hallucinations
Arrests/legal history
Sexual activity
Purposely causing injury to self
No fear of strangers
Preoccupation with violence
Abuse of internet
Other (please specify):
Any additional comments or information that you think would be important for us to know to help understand this child/teen better?
Signature of Person(s) Completing This FormDate of Completion