Chief Complaint/Concern

Child & Adolescent Questionnaire

Client /Child's Name: / Date of Birth:
Address: / Is the child adopted?
Who has legal custody of the child? / Is the child a foster child?
Child’s School And Grade: / Child’s Gender
Mother's Name: / Age:
Address: / Education:
Occupation: / Place of Employment:
Phone Number: / Okay to call (circle)? yes no
Marital Status (circle): Married Divorced Separated Widowed Single Other: / Explain:
Father's Name: / Age:
Address (if different from child's): / Education:
Occupation: / Place of Employment:
Phone Number: / Okay to call (circle)? yes no
Marital Status (circle): Married Divorced Separated Widowed Single Other: / Explain:
Step-Mother's Name: / Age:
Address (if different from child's): / Education:
Occupation: / Place of Employment:
Phone Number: / Okay to call (circle)? yes no
Step-Father's Name: / Age:
Address (if different from child's): / Education:
Occupation: / Place of Employment:
Phone Number: / Okay to call (circle)? yes no
People living in the same house as the child (do not list parents / step-parents): / Relationship: / Age:
Siblings not living in the same house as the child: / Relationship: / Age:

Chief Complaint/Concern

AggressiveImpulsive or Dangerous BehaviorLying

Anxiety Interpersonal Conflict/Peer ProblemsTemper outbursts

Binging/Purging ArgumentativeTruancy

Can’t Relate to OthersIrritability Academic performance

Concentration DifficultiesLow/High EnergyDestructive

Defiant BehaviorMedical Problems/Physical complaintsRunAway Attempts

Bed WettingDaytime Wetting/SoilingLacks Initiative

Depressed MoodFire setting/Playing with FireMood Swings

Difficulty Making DecisionsObsessive CompulsiveSelf-Mutilation

DisobedientHead bangingStrange Behaviors

Alcohol UsePanic AttacksStrange Thoughts

Drug UseFeels HelplessPhobic

RockingSleeping problemsChild Abuse/Neglect

Short Attention Span/DistractibleChange in AppetiteFamily Violence

Suicidal talk/thoughtsTrouble with the Law Other:______

Why is your child / family seeking therapy at this time?______

______When did the problemsbegin? ______

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What have you done recently or in the past to help with these concerns?______

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What changes would you like to see in your child? ______

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What changes would you like to see in yourself? ______

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What changes would you like to see in your family? ______

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Child's Developmental History:

Was this a planned pregnancy? Yes No Was the pregnancy full term? Yes No ______Wks/Mths

Was regular medical care given during the pregnancy? ______

Were there any complications or problems during pregnancy? If yes, describe the problem and time it occurred during pregnancy, such as diabetes, excess vomiting, bleeding, high blood pressure, toxemia, weight loss, fever, accidents, etc. ______

______

Were cigarettes, alcohol, or other prescription or non prescription medications used? What, how much, and how often? ______

Were there any complications or problems during the delivery or shortly after the child’s birth, such as emergency C-Section, slow heart rate, cord around neck, oxygen or medications needed, etc.______

______

Client’s Birth Weight: ______

Temperament as a baby (circle all that apply): Easy goingAnxious/FussyCheerful

Good SleeperResponsive when Cuddled

At what age did your child:

Sit without help? ______Say single words meaningful]y?______

Crawl?______Combine 2 or more words? ______

Walk without help? ______Use sentences?______

Become toilet trained? ______

Stop having accidents at night? ______

Start sleeping independently? ______

Child’s School History:

Has your child ever repeated a grade? If yes, which grade(s)?______

Have you ever requested an evaluation through your school or through another public school system? If yes, provide date(s) and reasons for evaluations: ______

Does your child have an IEP or 504 plan? ______

Does your child receive: Speech/language therapy Physical therapy Occupational Therapy

Special Education Instruction Specify subjects: ______

Tutoring Specify subjects: ______

If not currently, has your child received any of the above services in the past? Please specify. ______

Please list any concerns you have about your child’s ability to learn at an age/grade appropriate level and/or to socialize with other children. ______

______

Who is/are the appropriate person(s) to contact for details about your child’s school work? ______

______

Child’s Medical History:

Does your child have any of the following (please circle)? Yes No and describe if applicable:

Health Concern / Explain / Health Concern / Explain
Appetite / Weight Problems / Neurological Problems / Seizures
Breathing Problems / Sleep Problems
Cancer / Stomach / Bowel Problems
Diabetes / Allergies
Hearing / Vision / Speech Problems / Headaches
Heart / Kidney / Bladder / Liver / Gallbladder Problems / Other Health Problems/Concerns

Does your child have a history of frequent ear infections? If so, how often, at what age, and were any medical treatments provided?______

______

Does your child currently take any medications? If so, please provide the following information:

Name of Medication / Amount/Frequency/Start Date / Reason Prescribed / Prescribing Physician

Who is your child’s primary doctor? Please list name and address of practice:______

______

Date of Last Exam:______Are your child’s immunizations current? ______

Are there other things about the child’s health or previous treatment which may affect his or her care?

______

Substance Use Concerns

Are there any concerns about substance abuse? If yes, what substances has the child used? ____

______

Family Psychiatric History

Does anyone in your child’s family or household have any of the following?

Condition / Yes / Comments and Who:
Depression
Anxiety
Psychiatric Hospitalizations
Alcoholism or Drug Use
Suicide or Attempted Suicide
Learning Problems
Legal Problems
Seizures
Mental Retardation
Domestic Violence, Sexual or Physical Abuse
Stuttering or Speech Problems
Other (Specify):

During the past 12 months, has your family experienced:

____Death/Serious illness of a family member____Change in address

____Unemployment____Change in school

____Marital problems____Birth or adoption of new baby/child

____Other Stressors or Changes: ______

Number of moves in child’s life: ______Does your child share a room with anyone else? ______

Has your child ever been in legal trouble, including probation? If so, please describe: ______

______

Has your child ever been suspended or expelled? If yes, how many times? Explain. ______

______

Has your child even been physically or sexually abused? If yes, please explain. (Please note that by law, known or suspected abuse must be reported to Child Protective Services.) ______

______

Has your child ever received counseling services? If so, please list prior therapists/psychiatrists, start and stop dates, reasons for treatment, and any formal diagnoses. ______

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Has your child ever made a suicide attempt? If yes, when? What happened? ______

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What does your child enjoy doing? ______

What are your child’s greatest strengths? ______

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Is there anything else you feel I should know about your child? ______

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How did you find out about this practice? ______

I hereby certify that the information provided on this form is true and complete to the best of my knowledge.

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Signature of Parent or Legal GuardianRelationshipDate

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Signature of TherapistDate