PRETREATMENT ASSESSMENT (Ages 18 and Under)

HOPEFUL HEARTS COUNSELING

2211 Peoples Road Suite C

Bellevue, NE 68005

Voice: (402) 916-9886 Fax: (888)754-4926

PRETREATMENT ASSESSMENT (ages 18 and under)

DATE COMPLETED:

Client's Name: Gender:

Date of Birth: Age: Grade:

Form Completed by (if someone other than client):

Address: City: State:Zip:

Phone:

SSN: INS:

If you need more space for the following questions please use the back of the sheet.

Primary Reason(s) for Seeking Services:Circle all that apply and/or complete the other mental health concern area:

Anger Management _Anxiety _Coping _Depression_Eating Disorder _Fear/Phobias _Mental Confusion

Social Concerns _Sleeping Problems_ Addictive Behaviors_Alcohol/Drugs _Hyperactivity

Other Mental Health Concerns:

Family Information:

Mother (Name, age, location of residence)

Father (Name, age, location of residence)

Siblings (Name, age, location of residence)

SignificantOthers:

Mother's Occupation:

Where Employed: Work Phone:

Number and Dates of Marriage(s):

Father's Occupation:

Where Employed and Work Phone:

Number and Dates of Marriage(s):

Parents married?No If Yes when and how long:

Parents separated?No If Yes when and how long:

Parents divorced? No If Yes when and how long:

Child raised by someone other than biological parents? No If Yes who, why and how long?

State intervention(s) If Yes when and why and how long?

DISCIPLINE

How does the mother discipline the child?

For what reasons is the child disciplined by the Mother?

How does the father discipline the child?

For what reasons is the child disciplined by the Father?

DEVELOPMENT

Has the Mother had any miscarriages or stillborn children? IfYes,describe circumstances:

Was the pregnancy planned? Yes /No; Length of Pregnancy:

Mother's age at Birth and Father's age atBirth of Child:

How many pounds did the Mother gain?

Did Mother smoke during pregnancy? If yes how much?

Did Mother use drugs or alcohol? If yes, how much?

Did Mother have emotional or medical difficulties during pregnancy? If yes describe:

Length oflabor:Natural/ Induced/Caesarean/Vaginal:

Baby's birth weight: Baby's Birth length:

INFANCY/TODDLERHOOD Circle all that applies:

Breast Fed Milk Allergies Vomiting DiarrheaBottle FedRashesColic Constipation Not cuddle Cried often Rarely Cried Overactive Resisted Solids Trouble Sleeping Irritable when awake Lethargic

Describe any emotional or medical complications with delivery:

Describe any complications for the mother or baby after birth:

Length of hospitalization for Mother and for Baby:

Are there any special, unusual, or traumatic circumstances that affected child'sdevelopment? If Yes, please describe:

DEVELOPMENTAL MILESTONES: Please note the age at which the following behaviors took place:

Sat alone: Dressed self: Took 1st steps: Ties shoe laces:

Spoke full words: Rode two wheel bike: Spoke sentences: Toilet trained:

Weaned: Dry during day: Fed self: Dry during night:

Compared to other in the family, this child's development was: slow average fast

Age for following developments (if applicable)

Began Puberty/Menstruation /Voice change:

Problem behaviors:

Vocation/Job:

Has there been a history of child abuse? If yes what kind? (Please circle all that applies) Victim, Physical, Sexual, Mental, Emotional, Neglect

Perpetrator? Physical Sexual Mental Emotional Neglect

Any additional information on development?

SOCIAL RELATIONSHIPS

Circle how this child generally gets along with other people (all that apply):

Affectionate Aggressive Avoidant FightArgue oftenFollowerFriendly Leader Outgoing Shy/withdrawn Submissive Other(specify):

LEISURE and RECREATIONAL

Describe areas of interest or hobbies and any changes in them:

HOW OFTEN IN THE PAST? NOW?

CUL TURAL and ETHNIC

To what ethnic or cultural group, if any, does this child identify with?

Are there any issues surrounding this affiliation?

SPIRITUALITY AND RELIGION

Are you affiliated with a spiritual or religious group? If Yes please describe:

If Yes, name of church or meeting place?

How important is your Spiritual or Religious beliefs to you?

Were you raised within a Spiritual or Religious affiliation? If Yes please describe:

EDUCATION

Location Age(s)

Has child ever been suspended from school? If Yes please describe when, where, why:

LEGALCURRENT STATUS

Are you involved in any active cases? If Yes please describe with indicate court dates andcharges:

Are you currently on probation or parole? If Yes please describe:

PAST HISTORY

Traffic Violations: Date __ DWI, DUI, ETC If Yes-Date:

Criminal Involvement: If Yes-Date and Reason

Civil Involvement: If Yes-Date and Reason

Please elaborate on any Yes answers:

VOCATION

Does the child work? If Yes, please describe job, dates, hours and duties:

What is the child's attitude towards work?

Has this gotten better or worse in the last 6 months?

Has the child's grades been affected since working? If yes, how?

How many jobs has the child had?

Usual Length of employment by one institution?

MEDICAL and PHYSICAL HEALTH

(PLEASE CIRCLE ALL THAT HAVE APPLIED)

AbortionBronchitisCongenital ProblemsDiphtheriaEar InfectionsFevers

HepatitisLead PoisoningMiscarriageMuscular DystrophyParalysisPolio

Scarlet FeverSevere Head InjuryAsthmaCerebral PalsyCroupDizziness

EczemaHay feverHivesMeaslesMultiple SclerosisNose Bleeds

PleurisyPregnancySeizuresSexually Transmitted Dis.Blackouts

Chicken PoxDiabetesEar AchesEncephalitisHeart ProblemsInfluenza

MeningitisMumpsOther skin rashesPneumoniaRheumatic Fever

Severe ColdsThyroid disordersVision Problems Wearing Glasses Whooping cough

Other (Please describe)

Are there any current health concerns?

Are there any recent physical or health changes?

NUTRITION

Breakfast Number of times a week? How much eaten?Foods normally eaten?

Morning Snack Number of times a week? How much eaten?

Lunch Number of times a week? How much eaten?Foods normally eaten? _

Afternoon snack Number of times a week? How much eaten?

Dinner/Supper Number of times a week? How much eaten?Foods normally eaten?

Evening snack Number of times a week? How much eaten?

Favorite foods:

Food allergies: If Yes, what and result:

MEDICATIONS

Current Prescribed Medications (if more room is needed please use back of sheet):

Medication: Dosage: How long?

Are any over the counter medications taken regularly?

Medication: Dosage: Reason?

Are there any allergies to medications? If Yes please describe:

CHEMICAL USE STORY

Does the child/adolescent use or have a problem with alcohol and drugs? If Yes please describe:

COUNSELING PRIOR TREATMENT HISTORY

Are you currently receiving counseling services? If Yes please provide where, how long, and why:

Has the child previously received any mental health services in the past? If Yes, please provide when, how long, and reasons:

Do you feel that this child is currently in any danger of abuse, neglect, or suicidalideation or homicidal ideation? If Yes, pleasedescribe:

What is the main reason(s) for request for services?

How long has this/these problems persisted?

Under what conditions do these problems get worse?

Under what conditions do these problems seem to get better?

How did you hear of this clinic or who referred you?

Name and address of child's primary physician:

List any operations child has ever had andwhen:

Last doctor’s appointment and reason:

Last physical and results:

Are all immunizations current and up to date?

BEHAVIORAL AND EMOTIONAL INFORMATION:

Please CIRCLEall that are typical for this child:

AffectionateAggressive Alcohol problemsAngryAnxietyAttachment to dolls

Avoids adultsBedwettingBlinking, jerkingBizarre behaviorBullies, threatens

Careless, recklessChest painsClumsyConfident

CooperativeCyber addictionDefiantDepressionDestructive

Difficulty speakingEating disorderMemory problemsFrustrates Easily

GamblingGenerousHallucinationsHead bangingHeart Problems

HopelessnessHurts animalsImaginary friends ImpulsiveIrritableLazy

Learning problemsLies frequentlyListens to reasonLonerLow self-esteem

MessyMoodyNightmaresObedientOppositionalOver active

SadSelfishSeparation AnxietySets firesSexual addiction

Sexual acting outSharesSick often Short attention span Shy, timid

Sleeping problemsSlow moving SoilingSpeech problemsSteals

Stomach achesSuicidal threatsSuicidal attemptsTalks back Teeth grinding

Thumb suckingTics or twitching

Please elaborate on concerning behaviors:

List at least three strengths of this child:

1)

2)

3)

Please list at least three areas if improvement:

1)

2)

3)

What things does this child associate or play with?

What information, if any, do you feel that I should know prior to working with this childor that would help me to better understand this child?

Do you have any questions of me before working with this child?

Thank you for the opportunity to work with you and the child you care for.