Cucamonga Counseling

ChildPsychosocial Assessment(ages 4-11yrs)

Date of assessment:______

Name of child______Sex: (M)___ (F) ___

Birth date______Place of birth______Age______

Address (name and street)______

(city)______(state)______(zip code)______

Telephone ( )______Religion (optional)______

Education (grade)______Present school______

Referral Source:______

I give permission for (therapist) to contact (physician/teacher/etc.) regarding treatment issues, symptoms, behaviors or other information necessary for the treatment of (minor patient)

Parent Signature______Date______

CHIEF COMPLAINT:

Presenting Problems: (check all that apply)

__Very unhappy__Impulsive__Fire setting

__Irritable__Stubborn__Stealing

__Temper outbursts__Disobedient__Lying

__Withdrawn__Infantile__Sexual trouble

__Daydreaming__Mean to others__School performance

__Fearful__Destructive__Truancy

__Clumsy __Trouble with the law__Bed wetting

__Overactive __Running away__Soiled pants

__Slow__Self-mutilating__Eating problems

__Short attention span__Head banging__Sleeping problems

__Distractible __Rocking__Sickly

__Lacks initiative__Shy__Drugs use

__Undependable__Strange behavior__Alcohol use

__Peer conflict__Strange thoughts__Suicide talk

__Phobic

Explain:

How long have these problems occurred? (numbers of weeks, months, years)

______

What happen that makes you seek help at this time? ______

______

Symptoms:(Therapist to completes)

______

Danger To Self or Others:

Suicidal: yes/no Plan/intent______

Homicidal yes/no Plan/intent______

Previous Hospitalizations:

______

Past Mental Health Treatment/Medications:

______

Drug/Alcohol:

______

Family History MH:

Biological Parents: __married when______age______

__separated when______

__divorced when______

Step-parents: __married when______

Have any family members had any history of mental illness? If, so please explain:______

______

Childhood history:

Note all health problems the child has had or has now.

AgeAge

_High Fever___ _Dental Problems ___

_Pneumonia___ _Weight Problems ___

_Flu___ _Allergies ___

_Encephalitis___ _Skin Problems ___

_Meningitis___ _Asthma___

_Convulsions___ _Headaches___

_Unconsciousness___ _Stomach Problems___

_Concussions___ _Accident Prone___

_Head Injury ___ _Anemia___

_Fainting___ _High or Low Blood Pressure ___

_Dizziness___ _Sinus Problems___

_Tonsils out ___ _Heart Problems___

_Vision Problems___ _Hyperactivity___

_Hearing problems___ _Other Illnesses___

_Earaches___ (explain) ___

Has the child ever been hospitalized?__Yes __No

If yes, please explain.

Developmental History/Developmental Milestones:

Prenatal-Care? __Yes __NoPlanned for?__Yes __No

Normal pregnancy? __Yes __No

Drugs use during pregnancy? ___Yes ___No

Was mother ill or upset during pregnancy, explain:______

______

Length of pregnancy:______

Age at which child:

Sat up:______Crawled:______

Walked:______Spoke first word:______

Sentences:______Bladder trained:______

Bowel trained:______

Describe the manner in which toilet training was accomplished:______

______

Academic Performance:

What are your child’s recent grades?______

Any behavior problems in school?______

______

Does child participate in extracurricular activities? __Yes __No(explain)

Has child had special testing in school? (if yes, what were the results?) ______

______

Psychological __Yes __NoVocational __Yes __No

List the child’s strengths/special skills:

______

History of Abuse:

______

History of Legal Problems:

______

Religion:

______

Living Arrangements:

Who does the child currently reside with?______

______

PlacesDates

Number of moves in child’s life______

______

Does the child share a room with anyone else? __Yes__No

If yes, with whom?______

If no, how long has he/she had own room?______

Was the child ever placed, boarded, or lived away from family?__Yes __No

Explain:______

What are the major family stresses at the present time, if any?______

______

Brothers and Sisters: (indicate if step-brothers or step-sisters)

Name Age Sex

1.______

2.______

3.______

4.______

5.______

6.______

Other Family orSocial Support:

______

(Therapists Completes This Page)

Other/Comments:______

Goals:

______

Diagnosis

Axis I ______

Axis II ______

Axis III______

Axis IV______

Axis V______

Therapist Signature ______