Southeast Psychotherapy Associates, PLLC

Southeast Psychotherapy Associates, PLLC

PERSONAL INFORMATION – Child/Adolescent Form

Child’s Name:______Date:______

Informant:______Relationship to Child:______

Child’s Birthdate:______Age:______

Street Address:______

City:______State:______Zip:______

Home Phone: ( ___ )______Work Phone: ( ___ )______

__ Please do not call me at home __ Please do not call me at work

Mobile Phone: ( ___ )______Email Address: ______

__ Please do not call me on my mobile phone __ Please do not use my Email address

Insurance: ______ID#: ______Group #______

Policy Holder: ______Relationship to Client: ______

Employer:______

Policy Holders DOB:______Policy Holders SSN:______

Child’s School______Teacher’s Name______

Is child in special education? Yes No If so, what type?______

Father’s name______Age______Education______

Father’s place of employment______Type of Empolyment:______

Type of employment______

Mother’s name______Age______Education______

Mother’s place of employment______Type of Employment:______

Is child adopted? __ Yes __ No If yes, age when adopted ______

Are parents: Married __ Yes ___ No Separated? __ Yes __ No Divorced __Yes ___No

Other people living in client’s household:

Name:Age: Relationship:

______

______

______

______

Please describe your reasons for seeking therapy: ______

Has your child ever been in therapy before or hospitalized for psychiatric issues? If yes, please describe (therapist name, dates, reason): ______

Current Medications:

______

CURRENT SYMPTOMS; PLEASE MARK EACH CATEGORY:

NoneMild ModerateSevere Comment

Physical Problems______

Anxiety/Nerves Problems______

Depressed Mood______

Eating Problems______

Sleeping Problems______

Agitation ______

Aggressive Behavior ______

Conflict with others______

Does your child currently use alcohol or drugs that are not prescribed for him or her? ______

If yes, please describe:______

Does your child have a history of alcohol or drug abuse?______If yes, please describe and list the time of last use:______

MOTHER’S PREGNANCY AND DELIVERY

Length of pregnancy (e.g., full term, 40 weeks, 32 weeks, etc.)______

Length of delivery (number of hours from initial labor pains to birth)______

Mother’s age when child was born ______

Child’s birth weight ______

Please list conditions or problems that may have occurred during pregnancy, delivery or infancy. Please include use of illegal drugs or alcohol by the mother; seizures and congenital defects:______

INFANT HEALTH AND TEMPERAMENT

Please check any of these that occurred during the first 12 months:

_____Difficult to feed_____Sociable

_____Difficult to get to sleep_____Easy to comfort

_____Colicky_____Difficult to keep busy

_____Difficult to put on a schedule _____Overactive, in constant motion

_____Alert_____Very stubborn, challenging

_____Cheerful_____Affectionate

EARLY DEVELOPMENTAL MILESTONES

At what age did your child first accomplish the following:

Sitting without help______

Crawling______

Walking alone, without assistance______

Using single words (e.g., “mama,” “dada”, etc.) ______

Putting 2 or more words together (e.g., “mama up”) ______

Bowel training, day and night______

Bladder training, day and night______

HEALTH HISTORY

Date of child’s last physical exam: ______

At any time has your child had the following:

Never Past Present

______Asthma

______High Fevers (over 103)

______Broken Bones

______Lead Poisoning

______Speech/Language Problems

______Stitches

______Hearing Difficulties

______Soiling or Wetting Problems

______Fine Motor/Writing Problems

______Gross Motor Difficulties/Clumsiness

______Common Childhood Illnesses

______Appetite Problems (over or undereating)

______Sleep Problems (falling asleep, staying asleep)

______Chronic Illnesses

______Allergies

______Lengthy Hospitalizations

______Heart Problems

______Blood Pressure Problems

______Surgery

______Epilepsy/Seizure Disorder

______Eye/Vision Problems

______Chronic Ear Infections

______Other Health Difficulties; please describe:______

To Be Completed By The Teenager

CURRENT SYMPTOMS; Please Mark Each Category

NoneMildModerate SevereComment

Physical Problems:______

Anxiety/Stress:______

Depressed Mood:______

Eating Problems:______

Sleeping Problems:______

Agitation:______

Aggressive Behavior:______

Conflict with Others:______

HABITS:Amount/type currently usedMost ever used

Coffee (cups/day)______

Cigarettes (packs/day)______

Do you currently use alcohol or drugs? __ Yes __No

If yes, please answer the following:

If you do not currently use alcohol or drugs, did you use either in the past? __ Yes __ No

Last use:______

If yes, please answer the following: