Online Admission Packet

Children’s Program – Behavioral Health Services

Psychosocial and Family Assessment

IDENTIFYING INFORMATION

Date______(To be filled out by legal guardian or with their assistance)

______

Child’s first name Middle name Last name

Race ______Hospital where born ______Location ______

Child’s Address: ______City______State______

Zip Code ______Child’sHome Phone number: ______Child’s SS#:______

Child’s birth date______Child’s age______

How long has the patient lived in the current location? ______

Where else has the patient lived in the past five years? ______

______

Who is the legal guardian of the child: ______

Guardian's Address (if not parent & if different than child's) ______

City ______State_____ Zip Code______Guardian's Home Phone #______Guardian's Work Phone #______Guardian's Cell Phone #______

Emergency Contact ______

Name Relationship

Home #______Work #______Cell #______

FAMILY HISTORY

How long were the biological parents together?______

Are the parents currently: MARRIEDLIVING TOGETHERSEPARATEDDIVORCED

If separated/divorced, when did the separation/divorce take place? ______

Have the parents had additional marriages? YESNOIf “YES”, please identify date(s) of marriage(s) and divorce(s): ______

Does the child have contact with both biological parents? YESNO, why? ______

______

Is it okay to contact non-custodial parent? Yes No If no, explain______

Biological parents married when child was born?YESNO

If not together, date of parental separation (divorce, breakup, etc.)______

Name of Biological Father: ______DOB______SS#______

  1. Parental rights terminated? NO YES WHEN ______
  2. Address______City______State______ZipCode ______
  3. Phone: home#______cell# ______wk#______
  4. Employer______Occupation______
  5. Level of Education: Dropped out H.S. Trade Bachelor Master’s PhD/MD Other:______
  6. Mental illness, father or family? NO YES:______

______

  1. Substance abuse, father or family? NO YES: ______
  2. Any learning disabilities in family?NO YES: ______
  3. Military service history: NO YES: ______
  4. Any previous marriages? NO YES: ______# of kids from previous marriage: ______
  5. How did parent get along with own parents? ______
  6. How does child get along with him? ______

Name of Biological Mother: ______DOB______SS#______

  1. Parental rights terminated? NO YES WHEN ______
  2. Address______City______State______ZipCode ______
  3. Phone: home#______cell# ______wk#______
  4. Employer______Occupation______
  5. Level of Education: Dropped out H.S.Trade Bachelor Master’s PhD/MD Other:______
  6. Mental illness, mother or family? NO YES:______

______

  1. Substance abuse, mother or family? NO YES: ______
  2. Any learning disabilities in family?NO YES: ______
  3. Military service history: NO YES: ______
  4. Any previous marriages? NO YES: ______# of kids from previous marriage: ______
  5. How did parent get along with own parents? ______

12. How does child get along with her? ______

Other Adult involved with patient: ______DOB______SS#______

Relationship to child: Adoptive Parent Step Parent Legal Guardian Foster Parent Or: ______

  1. Address______City______State______ZipCode ______
  2. Phone: home#______cell# ______wk#______
  3. Employer______Occupation______
  4. Level of Education: Dropped out H.S.Trade Bachelor Master’s PhD/MD Other:______
  5. Mental illness, parent or family? NO YES:______
  6. Substance abuse, parent or family? NO YES: ______
  7. How does child get along with ______

Other adult involved with patient: ______DOB______SS#______

Relationship to child: Adoptive Parent Step Parent Legal Guardian Foster Parent Or:______

1. Address______City______State______ZipCode ______

2. Phone: home#______cell# ______wk#______

3. Employer______Occupation______

4. Level of Education: Dropped out H.S.Trade Bachelor Master’s PhD/MD Other:______

5. Mental illness, parent or family? NO YES: ______

6. Substance abuse, parent or family? NO YES: ______

7. How does child get along with ______

Who is responsible for child’s discipline ______

Place a check by any of the following methods used

Time out Restrictions  Loss of privileges  Spanking  Limited choices Praise Rewards

Other ______

Is there a Guardian Ad Litem involved? Name______phone#______

How long has the involvement been? ______

Siblings:(H-Half, F-Full, S-Step, A-Adoptive)

NameGender Age RelationshipWhere do they live

1) ______M F____ H F S A______

2) ______M F____ H F S A______

3)______M F____ H F S A______

4) ______M F____ H F S A______

Relationship with siblings: ______

______

Who is currently living in the home? ______

______

Isthere any information that cannot be disclosed to the patient at this time? NO YES (explain) ______

______

______

CURRENT LEVEL OF FUNCTIONING

Behavioral Profile (Put a star beside any behavior that has occurred in past month) If it is not a problem write NO for that question.

Describe any suicidal or self-harming behavior: ______

______

______

Describe any homicidal or assaultive behavior(onset, triggers) : ______

______

______

Describe any depression (onset, duration, what makes it worse): ______

______

Describe any psychotic behavior (onset, duration, triggers): ______

______

Describe the child’s usual mood:______

______

Describe any mood swings: ______

______

Describe any significant losses:______

Describe any pyromania (fire setting): ______

______

Describe any stealing: ______

______

Describe any cruelty to animals: ______

______

Describe any verbal abuse/swearing: ______

______

Describe any history of temper tantrums (If previous, when tantrums stopped?):______

______

Describe any destruction of property/vandalism: ______

______

Describe any day or night time wetting, soiling clothes, or urinating in inappropriate places: ______

______

Describe extent of any alcohol use or drug use or smoking: ______

______

Describe any lying: ______

______

Describe any running away: ______

______

Describe any poor hygiene: ______

______

Describe any impulsive behavior (doing without thinking): ______

______

Describe any problems with memory or concentration (onset): ______

______

Describe any risky behavior: ______

______

Describe any problems playing with others (is child invited to others’ houses for day, overnight?): ______

______

Describe any problems with peer group (what is typical relationship like with peers?):______

______

Describe any inappropriate sexual behavior (public masturbation, fondling, exposing self, etc.):______

______

How has the family reacted to the patient’s problems?______

______

PAST TREATMENT HISTORY

Where has the patient received therapeutic services in the past? (Most recent first, I-Inpatient, O-Outpatient)

Name of Agency/Therapist DatesLevelPrimary Referring Problem(s)

1)______I O______

2)______I O______

3)______I O______

4)______I O______

5)______I O______

Other services received: (and reasons previous services were stopped)

Case Management: ______

In Home Family Based Services/Dates:______

Parenting Classes/Dates:______

Neurological Evaluations/Dates:______

Any Psychological Testing done?NO YES ______

When: ______Where:______By whom:______

Why: ______I.Q.______

Who referred you to the Children’s Program? ______

CHILD'S MEDICAL HISTORY

List any drug allergies______

Child’s current height ______Child’s current weight ______

Child’s family doctor ______Office name______Phone #______

Has your child had problems with any of the following:

Three or more ear infections?NOYES______

Difficulty urinating or urinary infections?NOYES______

Constipation?NOYES______Diarrhea?NOYES______

Seizures/convulsions NOYES _______

Describe any sleep problems: (onset, what makes it worse, frequency of problem) ______

______

Describe any appetite problems (onset, what makes it worse, frequency of problem): ______

Describe your child’s eating habits/preferences______

Has your child had a change in appetite?NOYES______

Does your child follow a special diet?NOYES______

Have there been any weight changes in last six months?NOYES______

Does your child have any food allergies?NO YES______

Does your child wear braces or a retainer?NO YES______

Who is your child’s orthodontist? ______

Has your child had recent cavities or tooth pain?NOYES ______

When was your child’s last dental visit?______Name of dentist______

Hearing problems?NOYES______

Date/Place of last hearing test______

Vision problems? NOYES______

Date/Place of last vision exam ______

Allergies NOYES _______

Check if the child has had any of the following illnesses and when.

If none of these check here

 Roseola______Red Measles______German measles (Rubella) ______

Mumps ______Chicken Pox ______Asthma ______Jaundice ______

Pneumonia ______Broken Bones ______Whooping cough ______

Tonsils removed ______Adenoids removed ______

Describe any significant illnesses______

______

______

List any hospitalizations (reasons, dates, age of child) ______

______

______

List any outpatient surgeries (reasons, dates, age of child) ______

______

______

Has your child had a head injury in the past? NOYESWhen______Loss of consciousness? NOYESDescribe______

Has your child had any of the following tests? If so, please state why, when and where.

MRI NO YES ______

______

CT scan NO YES______

______

EEG (test for seizures) NOYES _______

______

Check any of the following that the child’s biological family members have had (include parents, siblings, grandparents, aunts, uncles and first cousins) Write the relationship on the line beside the illness.

Asthma ______Seizures ______Depression ______

Diabetes ______Tuberculosis ______High blood pressure ______

Bipolar illness ______Genetic disease ______Anxiety ______

Drug abuse ______Alcohol abuse ______High cholesterol ______

Heart disease before the age of 35 (for example: sudden cardiac death or fainting (syncope). If yes, please describe in detail______

______

______

List child’s current medication/dosage, who prescribes them and why it is taken

Medication______Dose______Times______Doctor______

Response ______how long on med ______

Reason for med ______

Medication______Dose______Times ______Doctor______

Response______how long on med______

Reason for med______

Medication______Dose______Times ______Doctor______

Response______how long on med______

Reason for med______

Medication______Dose______Times ______Doctor______

Response ______how long on med______

Reason for med _______

List any medications your child has taken in the past, when it was taken and why it was stopped

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______
  6. ______
7.______
CHILD'S DEVELOPMENTAL HISTORY

Was pregnancy planned? NOYES Birth weight ______Full term or early ______

Problems during pregnancy/birth? NO YES: ______

Any history of prenatal substance exposure?NO YES: ______

Any history of postpartum depression?NO YES: ______

History of miscarriages/abortions prior to this delivery?NO YES ______

Birth - infancy

Any negative responses to separation from parents, feeding schedules, change?NO YES______

______

What was the parent/child relationship during infancy? ______

Any family changes/stressful events during this time?______

Toddler years: (1 – 4 years old)

When did the child start walking? ______talking? ______toilet trained? ______

Any toilet training problems/regressions? NO YES______

Any behavior or temperament problems? NO YES ______

______

What age did you first notice problems in your child’s behavior?______

What was the parent/child relationship? ______

Any family changes/stressful events during this time?______

Childhood years: (five – twelve years old)

What was the parent/child relationship? ______

Any family changes/stressful events during this time?______

Describe child’s strong points: ______

Did your child attend daycare? NO YES What ages did they attend?______

Any behavior problems? NO YES ______

NEGLECT AND ABUSE HISTORY

Any history of physical abuse?NO YES______

______

______

Any history of sexual abuse (including rape)?NO YES______

______

______

Any history of neglect?NO YES______

______

Any exposure to violence (movies or domestic violence)? NO YES______

______

Has Social Services ever investigated the family or patient? NOYES

When?Why?Findings/Result of Investigation

1) ______

2) ______

EDUCATIONAL HISTORY

CurrentSchool______Current grade______Last school grade completed ______

Name of primary school contact: ______

Type of educational disability if child is in special education

LD (learning disability) grade started ______

 EBD (emotional behavioral disabled) grade started ______

 EMD (educable mentally disabled. IQ 50 – 70) grade started ______

 OHI (other health impairment) Reason______Example ADHD, bipolar disorder, medical conditions

When it started ______

Type of school classroom – please write when that placement started if other than a regular class

 Regular classroom education? ______

Resource: How many periods per day? ______When started?______

Self – contained class room - When started? ______

Has your child had any educational testing other than testing all children receive (standardized)?NO YES If yes, then when and where? ______

Special education services or 504 Plan?NO YES______

Does the child have an I.E.P.?NO YES _______

Peer/Teacher Relations______

Preferred Learning Method: Visual Auditory Tactile

Recent school performance (grades, behavior):______

______

______

How frequently is your child sent to the principal’s office? ______

How frequently are you called about your child’s school behavior? ______

Has your child been suspended?NO YES ______

Has your child ever repeated a grade? NO YES______

Number of days of school missed in past year? 0-56-1011-15>15

Past schools ______

______

Speech therapyWhen______Where______

 PT (physical therapy) When______Where______

 OT (Occupational therapy) When______Where______

*If available - Please enclose a copy of the psychological testing results, IEP or 504 Plan.

ENVIRONMENTAL AND CULTURAL FACTORS

Cultural and Spiritual Needs/Issues

Spiritual affiliation? ______

Active in cultural or spiritual activities?NO YES: ______

Cultural/environmental factors that may interfere with treatment? NO YES: ______

______

Leisure/Recreation Interests

What are the patient’s interests/hobbies?______

______

Types of movies child likes to watch?______

What kind of video games does your child like?______

Hours of TV, video games, computer per week? <1011-24>25

Environmental Needs

Patient has stable housing? YES NO: ______

Neighborhood safe?YES NO: ______

Do you receive your drinking water from a private well? YES NO ______

Are guns stored in the house? YES NO Are they locked up?YES NO

Other environment concerns?______

______

Discharge Plans for after Residential Treatment:______

______

______

Available Community Resources

Put a check mark beside the support systems or community resources you have available to you – even if you do not use them. Circle the ones that you use.

ChurchAfter school programsMental Health Services

Dept. of Social Services ProbationNeighborhood Community Center

Extended familyAdvocacy GroupNeighbors

Big Brother/Big Sister Autism Society Dept. of Disabilities & Special Needs

Continuum of Care Other Other

MEDICAL INSURANCE INFORMATON

Medicaid number______

Primary insurance

Name of insurance company______

Phone number______Group number______

Policy holder______Relationship to child______

Policy holder birth date______Policy holder SS # ______

Secondary insurance

Name of insurance company______

Phone number______Group number______

Policy holder______Relationship to child______

Policy holder birth date______Policy holder SS # ______

PLEASE INCLUDE THE FOLLOWING INFORMATION

*A CURRENT PICTURE OF YOUR CHILD

*A COPY OF YOUR CHILD’S IMMUNIZATION RECORDS

*A COPY OF CUSTODY PAPERS IF APPLICABLE

______

Signature of Person completing this form/relationship to child Date/Time

______
Reviewing Nurses Signature Date/Time
______
Reviewing Physician Signature Date/Time
______
Reviewing TherapistSignature Date/Time
______
Reviewing Teacher Signature Date/Time

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