Confidential Child Health - Parent Questionnaire

Deborah Mauldin, LICSW 425) 877-9808

16300 Mill Creek Blvd, #207, Mill Creek, WA 98012

Confidential Child Health - Parent Questionnaire

Patients Name ______Nickname ______Today’s Date ______

first middle last

Birth Date ______Age ______Sex: Male _____ Female _____

Name of Parent/Guardian #1 ______Birth Date ______

Preferred phone contact # ______Email ______

Address ______City ______Zip ______

Home Phone ( ) ______

Employed by ______Occupation ______

Work Hours ______Business Phone ( ) ______

Name of Parent/Guardian #2 ______Birth Date ______

Preferred phone contact # ______Email ______

Address ______City ______Zip ______

Home Phone ( ) ______

Employed by ______Occupation ______

Work Hours ______Business Phone ( ) ______

In case of emergency, please contact: ______Phone ( ) ______

Referred by:

Please describe, in detail, the present problem (including when the problem started, how often it occurs, what stressors may be contributing to the problem… Please feel free to use reverse side of this form)

Has your child received any previous treatment for this problem? □ No □ Yes (If yes, please list provider or counselor’s name, location, dates of services, and outcome of treatment)

What do you hope to gain from this referral?

What do you consider to be some of your child’s strengths?

What do you consider to be some of your child’s challenges?

FAMILY INFORMATION:

Parent’s Marital Status: □ Married □ Domestic Partnership □ Separated □ Divorced

If divorced, has either remarried? Father?□ No □ Yes Stepmother’s Name ______

Mother remarried? □ No □ Yes Stepfather’s Name ______

If biological parents are divorced or separated, what are the physical custody arrangements?

______

Is your family spiritual or religious? □ No □ Yes Please describe your faith or belief:

______

Please list all the individuals that live in the same household(s) with your child:

NameRelationship to your child

______

Are any of these stressors impacting your family or your child at this time? Please describeany checked issue.

□ School problems
□ Health concerns
□ Legal issues
□ Marital discord
□ Financial stress
□ Employment conflicts or job changes / □ Death of a family member or someone close to the family
□ Drug or alcohol problems
□ Abusive behavior
□ Struggles with parenting and child rearing
□ Changes in household or frequent moving
□ Other, please describe:

Any history of prolonged separation from mother and/or father? (What age? How long? Child’s reaction to separation?) ______

CHILD’S MEDICAL HISTORY:

Primary Pediatrician or Family Physician ______Phone # ______Last physical exam ______Last hearing test ______Last Vision test ______

List any specialists your child sees ______

Medications

Please list current prescribed medications and anypsychiatricor mood medications that your child has been prescribed in the past.

Name of Medication / Prescribed by / Dates / Dose / Side Effects / % Improvement

Please list current over the counter medications and supplements

______

Any Allergies?______

Medical Conditionsyour childhas had or has been diagnosed with:

Yes No OnsetYes No Onset

ADHD/ADD / Fainting
Anxiety/ Fears / Hearing Loss
Asthma / Head Injury
Broken Bones / Knocked out
Chronic Ear Infections / Seizures
Chronic Headaches / Stomach aches
Concussion / Tics
Depression / Vision problems
Diabetes / Weight loss/gain

Other major illnesses, operations, injuries or conditions (please describe and give the year or age at the time)

Has your child ever had a MRI or CT brain scan or EEG? □ No □ Yes If yes, please explain

Developmental Disabilities or Challenges (visual, hearing, fine motor, gross motor, speech, etc.) □ No □ Yes If yes, please describe:

Describe your child’s sleep patterns? (time to fall asleep, duration sleep, night terrors, frequent awakenings, bedwetting, nightmares, sleeping walking, etc.):

Eating patterns (healthy, flexible, finicky, restrictive, binge eating, etc.):

FAMILY MEDICAL HISTORY:

□ Sudden death before 50 / □ Heart Disease / □ Obesity
□ Sudden heart attack before 50 / □ Irregular heart rhythms / □ Seizures
□ Narrow Angle Glaucoma / □ Thyroid Disease / □ Diabetes
□ Other

FAMILY PSYCHIATRIC HISTORY:Any parent, grandparent, or sibling with any of the following?

Yes No Who Yes No Who

ADHD/ADD / Learning Disabilities
Alcohol problems / Obsessive Compulsive
Anxiety or Fears / Seizures
Bipolar Disorder / Suicide
Depression / Tics
Drug Problems / Tourette’s
Eating Disorders / Schizophrenia

EARLY DEVELOPMENTAL HISTORY:

Prenatal and Birth History

Adopted? □ No □ Yes If yes, at what age?

Please check any that apply to the mother’s pregnancy with this child:

□ Received prenatal care□ Diabetes of pregnancy□ Severe emotional distress

□ Took medications□ Threatened miscarriage□ Smoked during pregnancy

□ Infections□ Premature labor□ Drank during pregnancy

□ Nausea and vomiting□ Weight loss□ Used drugs during pregnancy

Mother’s age at time of birth? ______Father’s age at time of birth? ______

Any complications with pregnancy or delivery ? □ No □ Yes If yes, please explain

Were they any problems after birth? □ No □ Yes If yes, please explain

Post delivery blues or post-partum depression? □ No □ Yes If yes, please explain

Breast fed? □ No □ Yes Food allergies? □ No □ Yes If yes, please explain

Toddler/Pre-school Temperament: Please check any of the following that apply.

□ Did not enjoy being held□ Excessive restlessness□ Colic

□ Feeding problems□ Sleep problems□ Head-banging

□ Sensitive to light/noise/texture□ Fussy or unhappy□ Difficulty bonding

Developmental Milestones: Please indicate the approximate age in months when your child achieved the following tasks:

AGE

Sitting□ Normal□ Early□ Late

Walking□ Normal□ Early□ Late

Speech and Language□ Normal□ Early□ Late

Toilet Trained□ Normal□ Early□ Late

Self-help skills (dressing, hygiene)□ Normal□ Early□ Late

SCHOOL HISTORY:

What were your child’s grades on their last report card? ______

Have report cards or school conference indicated any special difficulties?

□ Classwork □ Behavior □ Attitude

Explain: ______

Has your child ever been evaluated for a learning disability, had an IEP (Individual Education Plan), or placed in Special Education Classes? □ No □ Yes If yes, when and please explain?

______

How does your child feel about going to school? ______

Performance in academic subjects (check a box for each subject the child takes):

BelowAbove

Failing Average Average Average

Reading, English, Language Arts□□□□

Math□□□□

Science□□□□

History or Social Studies□□□□

Other: ______□□□□

SOCIAL HISTORY:

About how many close friends does your child have? (Do not include siblings)

□ None □ 1 □ 2 or 3 □ 4 or more

About how many times a week does your child do things with any friends outside of regular school hours?

□ Less than 1 □ 1or 2 □ 3 or more

Compared to others of his/her age, how well does your child:

Worse Average Better

Get along with his/her brother & sisters?□□□

Get along with other kids/peers?□□□

Behave with his/her parents?□□□

Play and work alone?□□□

Please list the sports your child most likes (such as swimming, baseball, bike riding, fishing, etc.)

______

Please list your child’s favorite hobbies, activities, and games (such as piano, books, dolls, computers, music…)

______

Please list any organizations, clubs, teams or groups you child belongs to.

______

Please list any jobs or chores your child has.

______

CHECKLIST

Please check any issues listed here that describe your child:

□ Acts too young for his/her age
□ Argues a lot
□ Can’t concentrate or pay attention for long
□ Can’t sit still, restless, or hyperactive
□ Destroys things belonging to others
□ Disobedient at home
□ Disobedient at school
□ Fails to finish things s/he starts
□ Too fearful or anxious
□ Feels worthless or inferior
□ Impulsive acts without thinking / □ Feels too guilty
□ Self –conscious or easily embarrassed
□ Inattentive or easily distracted
□ Temper tantrum or hot temper
□ Threatens people or hurts others
□ Self harm
□ Unhappy, sad or depressed
□ Worries
□ Physical problems without medical cause
□ Loss of interest in usual activities
□ Loss of relationships or friends

Please tell me about any problems your child has that were not referenced in this form or feel free to elaborate on your concerns or factor impacting your child/teen or your family on the reverse.

DEBORAH MAULDIN, LICSW

16300 Mill Creek, Blvd, #207 Mill Creek, WA 98012

CONDITIONS OF ADMISSION AND CONSENT TO TREAT

Consent to Treatment

I give my consent to Deborah Mauldin to provide my child and my

family outpatient counseling and psychotherapy care.

I understand that my child’s acceptance is contingent upon parental/

guardian participation if such is considered necessary by the therapist.

Confidentiality

I understand my child’s files and records are confidential and will not

be released to outside individuals or agencies without expressed written

consent. However, certain information maybe released by the therapist

without my authorization, under certain circumstances, including the following:

a)upon receipt of a court order

b)in event of a valid medical emergency

c)if there is evidence to suggest that child abuse has occurred

d)when danger to public (such as homicide) or self (such as suicide

or threat of suicide) requires disclosure

e)in cases where there is legal joint custody

______

Parent/Legal Guardian

______

Date