Park Ridge Psychological Services

History and Questionnaire re: Child/Adolescent

Please complete this form as accurately and as fully as possible.

Client Information

Patient’s Name:______Date of Birth:______Age:_____ Gender:______

Occupation/School:______Grade:______Marital Status:______

Home Address:______

Home Phone: (______)______Cell#: (______)______Work#: (______)______

Responsible Party (if not client)

Name:______Occupation:______

Marital Status:______Emergency Contact:______Phone: (______)______

Who referred you to Park Ridge Psychological Services?______

Why have you come to us at this time/What do you hope to accomplish from your time here? ______

______

Have you attempted to solve these problems before? If so, when and how?______

______

What about past attempts at solving the problem(s) was not helpful? ______

______

Family Constellation

Who lives at home with the client? (please include extended family and pets)

Name:______Relationship:______Age:______

Describe the relationship between this person and the client:______

Name:______Relationship:______Age:______

Describe the relationship between this person and the client:______

Name:______Relationship:______Age:______

Describe the relationship between this person and the client:______

Name:______Relationship:______Age:______

Describe the relationship between this person and the client:______

Name:______Relationship:______Age:______

Describe the relationship between this person and the client:______

Who else in the client’s family is important to him/her?______

Are there any conflictual relationships in the home? If so, please describe:______
______

Please describe the marriage of the client’s parents:______

______

Please describe any important family events (e.g., divorces, remarriages, deaths, traumas, losses, significant moves, etc.):______

______

______

Natural Mother’s History:

Age:______Career/Profession:______Education:______

Any history of drug/alcohol use/abuse:______If yes, please describe:______

Any history of learning/attention problems?______

Any medical problems?______Any evaluation or treatment for emotional problems?______

Please describe briefly mother’s family of origin, including significant conflict, history of emotional/learning problems:______

______

Natural Father’s History:

Age:______Career/Profession:______Education:______

Any history of drug/alcohol use/abuse:______If yes, please describe:______

Any history of learning/attention problems?______

Any medical problems?______Any evaluation or treatment for emotional problems?______

Please describe briefly father’s family of origin, including significant conflict, history of emotional/learning problems:______

______

Step-Parent or other parental figure History:

Age:______Career/Profession:______Education:______

Any history of drug/alcohol use/abuse:______If yes, please describe:______

Any history of learning/attention problems?______

Any medical problems?______Any evaluation or treatment for emotional problems?______

Please describe briefly person’s family of origin, including significant conflict, history of emotional/learning problems:______

______

Developmental History

Parents’ attitude toward pregnancy:______Ease of conception:______

Complications of pregnancy/birth:______

Post delivery blues or postpartum depression?______If so, for how long?______

Diet/Sleep History: Breast vs. bottle______Age weaned______Food allergies______

Early sleep behavior: Sleepwalking, night terrors, dysregulation, etc. ______

Toilet training: Age reached bowel control: day______night______Bladder control: day______night______

Ease/difficulty with training______Current function:______

Sexual development: Any concerns regarding gender identity?______

Any suspected history of sexual acting out and/or sexual abuse?______

Motor development: How is his/her fine motor coordination?______Gross motor coordination:______

Language Development: When did the client: Say several words, besides mama, dada______Name several objects______

Put 3 words together (subject, verb, object)______How would you describe the client’s: Vocabulary:______Articulation:______Comprehension:______Oral reading fluency:______

Sensory Processing: Any areas of sensory processing (auditory, visual, tactile) that seem hypersensitive or undersensitive? ______

______

Social Development: How was the client’s attachment with mother growing up?______

How was the client’s attachment to father? ______

How is the client’s ability to make, maintain good friendships?______

Does the client have any significant hobbies or interests?______

How would you describe the client’s current relationships with same-sex peers?______

How are his/her relationships with opposite sex peers?______

Behavior/Discipline: How compliant was/is the client as a child?______What methods of discipline do/did parents use to shape the client’s behavior?______

Which methods were most successful/least successful:______

Any history of physical abuse?______

Do parents/guardians have similar/united discipline methods/philosophy? ______

Emotional Development: How would you describe the client’s temperament as a baby (e.g., colicky, happy, content, excitable, curious, etc.)?______

Any phobias/fears?______Any history of emotional abuse?______

Drug/Alcohol use/abuse: Please list all usage:______

______

School History: Current grade:______Current School:______Average grades:______

Homework problems:______Specific learning problems:______

What do/did teachers say about the client?______

Religious Development: What is the client’s religious background? ______Is his/her religious beliefs important to him/her or to the family? ______

Self-Identity Development: What is the client’s ethnic/racial background?______

Has the client experienced any discrimination due to ethnic/racial background?______

How would you rate the client’s self esteem on a scale from 1-10 (with 10 being the highest):______

Medical History:

Please explain in detail current and past medical problems/concerns:______

______

Current medications (with dosage, reason):______

______

Any side effects?______

Are you happy with the current medication regimen?______

How is the client’s current diet? ______

Does the client exercise regularly? (If no, are there any limitations?)______

How does the client sleep? (How many hours, is it interrupted, is there snoring, etc.)______

Who is the client’s Primary Care Physician?______

Etc.

What are the client’s personal strengths?______

______

What are the major stressors in the client’s life? Currently:______

In the past:______

What resources does the client have in aiding him/her in getting better?______

______

Is there anything else we should know about the client or his/her history or present situation that might help us better evaluate and help the client?______

______

Thank you very much for your attention to this history/questionnaire. If you recall anything important after you complete it, please feel free to contact the clinician.