Christine M. Larson, Ph.D.
Licensed Psychologist
401 Shady Avenue, Suite A104
Pittsburgh, Pennsylvania 15206
Phone: (412) 519-9549
Fax: (412) 361-2295
Client Information Form- Child
Please fill out this form as fully and openly as possible to help us begin our work together.
Identification and Contact Information Today’s date: ______
Child’s name: ______Date of birth: ______Age: ____
Child’s nickname: ______Social Security #: ______
Names of parents/guardians: ______
Address(es): ______
Parent email: ______Parentphone/cell:______
Indicate any restrictions on calls, messages, mail, or email:______
Name of person to contact in case of emergency: ______
Phone: ______Address:______
Referral: How did you find my name? ❑Insurance Company❑Internet Search (which?) ______❑Referred by: Name: ______May I thank this person for the referral? ❑ Yes ❑ No
Demographic and Education Information Ethnicity/national origin: ______
Gender: _____ Religious affiliation(s)?: ______Any serious food allergies? ______
Grade: ______School: ______School problems? ______
Does your child have difficulty separating to go to school? ______
What do teachers say about your child’s behavior at school? ______
Legal History
Do you have any current or upcoming legal involvements, such as lawsuits, custody, divorce/separation, protection from abuse orders, pending legal charges, past legal involvement, etc? ❑ No ❑ Yes
PLEASE NOTE: Dr. Larson does not provide custody evaluations, expert testimony, or other forensic services.
Health and Medical Care Pediatrician’s name: ______Phone: ______
Address: ______
How many hours of sleep does your child get daily? ______Trouble falling asleep at night? ❑ Yes ❑ No
Has your child gained/lost weight in the past year?❑ Yes ❑ No - Gained ____lbs. - Lost ____lbs.
Does your child have any chronic or acute physical illnesses which impact on mental health? ❑ Yes ❑ No
Has your child ever received psychological or psychiatric treatment or medication? ❑ Yes ❑ No
Has your child ever had a serious illness, injury, surgery, or hospitalization? ❑ Yes ❑ No
Family History
Relationship / Name / Current Age(or age at death) / Occupation
Father
Mother
Step-father
Step-mother
Brother(s)
Sister(s)
Other important relatives or non-biological family members:
Was your child or any of your child’s siblings adopted or raised with parents other than natural parents?
Early Development Was this child’s conception planned? ❑ Yes ❑ No
During pregnancy, the child’s natural mother did which of the following? ❑smoked tobacco ❑drank alcohol
❑was injured ❑had serious illness/surgery ❑used prescription drugs ❑ experienced other major stress
Did mother or child experience medical complications during or following delivery? ❑ Yes ❑ No
Was the baby carried to term? ❑ Yes ❑ No Birth weight/length ______APGAR scores ______
What adjectives best describe this child during infancy and toddler years? (examples: cuddly, clinging, distant, curious, demanding, angry, hyper, tense) ______
Did the child meet developmental milestones on time? (examples: sit, walk, speak, toilet training) Indicate delays:
______
How did the child respond to others from ages two to five? Please use this chart to describe:
ACTIVITY:HAPPYINDIFFERENTUPSET
Held by Mother
Plays Near Mother
Mother Leaves Child
Held by Father
Plays Near Father
Father Leaves Child
Stranger Approaches
Stranger Holds Child