Childhood History/Parent Interview

Appendix Z

CHILDHOOD HISTORY/PARENT INTERVIEW

DEPARTMENT OF PSYCHOLOGICAL SERVICES

CHLD’S NAME______SCHOOL ______

PARENTAL INFORMATION

Mother’s Name ______Father’s Name ______

Occupation ______Occupation ______

Age at birth of child ______Education ______Age at Birth of Child ______Education ______

PRIMARY CAREGIVERS:

Child is presently living with:

( ) Natural Mother( ) Stepmother( ) Foster Mother

( ) Natural Father( ) Stepfather( ) Foster Father( ) Other

Does anyone else take care of the child on a regular basis? If so, whom? ______

BROTHERS/SISTERS

List ALLbrothers and sisters, and any other children living with the family (If additional space is needed, please list on back)

Name / Relationship to Child / Age / Sex / Living at Home (Yes or No)

PREGNANCY/DELIVERY HISTORY

Was Child Premature? ( ) Yes ( ) NoLength of Pregnancy: ______

Hospitalization required during pregnancy? Please Check:( ) YES( ) NO

If YES, please give reason: ______

______

Complications during Pregnancy

Infections?( ) Yes( ) No If yes, specify: ______

Drug Use?( ) Yes( ) No If yes, specify: ______

Alcohol Use? ( ) Yes( ) No If yes, specify: ______

Smoke?( ) Yes( ) No If yes, specify: ______

Medications?( ) Yes( ) No If yes, specify: ______

X-Rays?( ) Yes( ) No If yes, specify: ______

Other (Please describe) ______

Delivery of your child

Type of Labor: ( ) Spontaneous ( ) InducedDuration in Hours: ______

Type of Delivery:( ) Normal ( ) Breech( ) Cesarean

Complications:( ) Cord Around Neck( ) Hemorrhage( ) Injured during delivery

( ) Other ______

Birth weight of child ______

Complications after delivery:( ) Jaundice( ) Infections( ) Incubator Care( ) Breathing Problems

Other ______

Appendix Z (p.2)

DEVELOPMENTAL HISTORY

As close as possible, at what age did this child do the following?

Turn over ______
Sit alone ______
Crawl ______
Stand alone ______
Walk alone ______
Walk up stairs ______/ Walk down stairs ______
Show interest or attraction to sound ______
Understand first words ______
Speak first words ______
Speak in sentences ______
Totally toilet trained ______

Describe any other special problems during first few years, such as eating, sleeping, coordination, speech, behavior, etc.:

______

MEDICAL HISTORY

Please check the illnesses this child has had and indicate age as closely as possible.

( ) Meningitis( ) Rheumatic Fever( ) Diphtheria ( ) Allergies?

( ) Encephalitis( ) Measles( ) Chicken Pox [ ] Food

( ) Fever above 104( ) Mumps( ) Seizures [ ] Medicine

( ) Sustained High Fever( ) Anemia What? ______

If the answer to any of the following is YES, please describe. If the answer is NO, please write NO.

( ) Vision Problems ______

( ) Ear Problems (Infections/Tubes/Injuries) ______

( ) Head Injury: Describe ______

( ) Coma or loss of consciousness: Describe ______

( ) Hospitalizations: Describe ______

( ) Long term medications (more than 6 months): When?______What Kind:?______

Has this child had previous psychological counseling/testing? ( ) Yes ( ) No

If Yes, when, by whom, and what was done?______

______

BEHAVIORAL CONCERNS

Check the following areas that are of concern to you regarding your child:

No Behavioral Concerns / ______/ Problems at Meals / ______
Sleeping / ______/ Disobedience / ______
Temper Tantrums / ______/ Thumb Sucking / ______
Speech / ______/ Appetite / ______
General Development / ______/ Gets Upset too Easily / ______
Shy, Clinging / ______/ Wants too Much Attention / ______
Activity Level / ______/ Wetting the Bed / ______
Soiling / ______/ Feelings Hurt Easily / ______
Sad or Unhappy / ______/ Discipline Problems / ______
Relationship with Brothers and Sisters / ______/ Relationships with Other Children
Selfish / ______
______
Restless Sleep / ______/ No Feelings of Remorse / ______
Nervous Sleep / ______/ Cruelty to Animals / ______
Stubborn / ______/ Destroying Property / ______

______
FAMILY HISTORY Appendix Z (p. 3)

Have any family members had any of the following medical conditions/learning problems? If yes, please specify relationship. If child is not currently living with natural mother and father, please include information for them.

( ) Tourette’s Syndrome ______( ) Birth Defect ______

( ) Tay-Sachs Disease ______( ) Mental Retardation ______

( ) Sickle-cell Anemia ______( ) Seizures or Epilepsy ______

( ) Alcohol/Drug Abuse ______( ) Reading ______

( ) Behavior/Emotional ______( ) Other Learning ______

( ) Mental Illness ______( ) Speech/Language ______

All families experience areas of concern at some point in time. If your family is experiencing difficulties in any of the following areas please check those that apply:

_____ Birth of a New Brother or Sister _____ Divorce, Separation, or other Martial Issues

_____ Recent Death or Illness of a Family Member _____ Concern over Parent(s) having to Work

_____ Recent or Frequent Moves _____ Other problems (such as financial, drugs, or Alcohol, etc)

_____ Day Care or Preschool ______

FRIENDSHIPS/INTEREST/BEHAVIOR OF CHILD

Has he/she have problems relating to or playing with other children?( ) Yes ( ) No

If Yes, please describe the problems:______

______

What activities does this child enjoy (sports, hobbies, etc.) ______

______

Please indicate whether this child exhibits any of the following behaviors:

( ) Has short attention( ) Withholds affection( ) Overstimulated in play

( ) Lacks self control( ) Hides feelings( ) Seems overly energetic

( ) Seems unhappy most of the time( ) Has fears( ) Seems impulsive

( ) Requires lot of attention( ) Overreacts to problems( ) Difficulty with new people

DISCIPLINARY METHODS

What behavior management techniques do you usually use with your child? Please check each.

( ) Ignore problem behavior( ) Send child to room( ) Take away privileges

( ) Verbally scold child( ) Spank child( ) Model appropriate behavior

( ) Verbal praise/feedback( ) Reward (treats, money, points)( ) Talk with child about behavior

( ) Redirect Child’s interest( ) Extra time for activity of choice (sports, TV, friends, etc.)

( ) Other ______

Describe behavior management techniques which are most effective? ______

______

Describe behavior management techniques which are least effective? ______

______

Appendix Z (p.4)

PREVIOUS SCHOOLS (INCLUDING NURSERY AND KINDERGARTEN)

If more space is needed, please use back

School ______City/State ______Grades ______

BRIEFLY DESCRIBE WHAT YOU FEEL ARE YOUR CHILD’S PROBLEMS AT THE CURRENT TIME:

______

BRIEFLY DESCRIBE WHAT YOU FEEL ARE YOUR CHILD’S STRENGTHS AT THE CURRENT TIME:______

PLEASE READ THE FOLLOWING AND SIGN

The above information is extremely valuable in aiding in the decision regarding the most appropriate educational needs of

your child and may be used as part of the psychological evaluation report. My signature below indicates that I am aware of

this and am in agreement.

______

Signature Date