Thank You for Your Cooperation in Filling out This Form
Student / Family History Information
Student’s Name: / M / F / Date of Birth:
Address: / Student’s Social Security # _ _ _ / _ _ /_ _ _ _
Apt #: / Current Medical Insurance:
City: / State: / Zip: / Insurance ID Number:
Home Phone #: / Parent’s email: / Religion: active _____ somewhat ______non-observant
Cell Phone #: / Ethnicity:
Legal Custody ( If divorced): / Language spoken at home:
Has the family consulted a Religious leader regarding Church /Family Problems: Y / N
PRESENTING PROBLEM: In a few sentences, please describe your child’s recent behavior which led you to bring him/her to IDT.
______
______
______
DEVELOPMENTAL HISTORY:
Child’s Birthdate: / Where was child born (Hospital): / City/State:
During pregnancy did mother (circle any that apply) :
take any medication, smoke cigarettes, drink alcohol, use drugs / Was the delivery: normal/vaginal C-section
Birth weight:
How was the pregnancy? Were there any medical complications for mother or baby? Y / N
If yes, please explain: ______
HISTORY:
Birth/Developmental History: Add additional information about family situation and early development if relevant to treatment.
Pregnancy:
Prenatal care?: Y / N / Length of pregnancy (months):
Illness/ Medications?: Y / N / Length of Labor (hour):
Any difficulties?: Y / N / Mother’s age when child delivered:
Comments:
Development:
Did the baby have colic?: Y / N / Any feeding problems?: Y / N
Did infant respond to environment?: Y / N / Any sleep problems?: Y / N
Comments:
Milestones – age at which child:
First stood: / Walked without support:
Spoke first word: / Spoke in 3 words:
Toilet trained or bladder: / Toilet trained for bowels:
Comments:
Was mother ever separated from baby? Y / N
If yes, for what reason? / How long? / Please provide details and dates. ______
How does your child relate to: Siblings ______Peers______Adults______
At what age did your child present behavioral difficulties?
MEDICAL HISTORY
Are there any concerns with your child’s: Physical development Y / N or Sexual Development Y / N. If so, please explain ______
For Girls Only: Age of first period ______.
FAMILY CONSTELLATION
Who lives in your home? (Please list all member of the household)
NAME / RELATIONSHIP / AGE / DATE OF BIRTH
Do you live in: House Apartment Trailer Shelter (Please circle one)
Are you currently employed? Y / N What is your occupation? ______
Name and Address of Employer:
______
______
______/ Are you employed : (Please circle one)
Full Time or Part Time
Please provide days and hours worked each week: ______
Are you: Married Separated Divorced Single (please circle one)
What kind of contact does your spouse (ex-spouse) have with student? ______
______
Is your spouse (ex-spouse) employed? Y / N What is his/her occupation? ______
Name and Address of Employer:
______
______
______ / Are you employed : (Please circle one)
Full Time or Part Time
Please provide days and hours worked each week: ______
FAMILY HISTORY
PATIENT’S MOTHER:
Name: ______Date of Birth:______
Where were you born? ______Where were you raised? ______
What level of education have you completed? ______
PATIENT’S FATHER:
Name: ______Date of Birth:______
Where were you born? ______Where were you raised? ______
What level of education have you completed? ______
What is the role of extended family in your child’s life?
Do you have any firearms in the House? Y / N If yes, are they locked up? Y / N
EDUCATIONAL HISTORY
Please provide names of school your child has attended and addresses:
SCHOOL / GRADE / LOCATION
SPECIAL EDUCATION: Is your child classified as needing special education? Y / N
If so, what grade was he/she classified? ______What type of classification? ED LD 504 other (please circle one)
Briefly describe any history of school problems. (include behavioral and or academic): ______
______
INTERPERSONAL:
What recreational activities/hobbies is your child involved in? ______
______
How does your child relate with other children at school and at home? ______
______
Does your child have friends? Y / N
The peers your child associates with are: Younger Same age Older (please circle)
How would you describe the impact of your child’s friends on their school performance and behavior? ______
______
PHYSICAL/SEXUAL ABUSE:
Does your child have a history of being physically abused? Y / N
If yes, did your child receive treatment for this problem? Y / N
If yes, where and when did they receive treatment ______
Does your child have a history of being sexually abused Y / N
If yes, did your child receive treatment? Y / N
If yes, where and when did they receive treatment? ______
Has anyone in the student’s family been a victim of domestic violence? Y / N
If yes, by Whom:______When:______
CHILD/FAMILY PSYCHIATRIC HISTORY
Has your child ever been in treatment / therapy / hospitalized before? Y / N
If yes, please list below
Name of Hospital / Reason for Admission / Name of Physician / Hospitalization Dates
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Outpatient / Clinic / Reason for treatment / Therapist Name / Dates of treatmentIs your child on medication NOW or in the PAST? If so, please list all medications:
Name of medication:______Dosage: ______
Prescribing Doctor:______Dates: ______
Name of medication:______Dosage: ______
Prescribing Doctor:______Dates: ______
Name of medication:______Dosage: ______
Prescribing Doctor:______Dates: ______
Any additional medications: ______
Has anyone in your family had psychiatric treatment or hospitalization? Y / N
Please give name(s), relationship to patient, reason for treatment and dates:______
______
LEGAL HISTORY
Have there been any legal proceedings involving your child? Y / N
If yes, please explain: ______
Circle any that apply:
Are there any court proceedings, PINS Petition, JD’s or sexual offenses for your child?
Were they ever any reports filed with CPS regarding your family or child? Y / N
If yes, please give date and reason for report. ______
______
DRUG/ALCOHOL ABUSE
Does your child have a history of using drugs or alcohol? Y / N
If yes, was your child in treatment for the problem? Y / N
Where and when did he/she received treatment: ______
Is there any history of drug or alcohol abuse for anyone in the student’s family (siblings, parents, grandparents, uncles, aunts, etc.)? Y / N ______
______Does student or any family household member smoke cigarettes? Y / N ______
Please describe and give dates where known: ______
______
STRENGTHS AND WEAKNESSES
Describe your child’s strengths: ______
______
Describe your child’s challenges: ______
______
THANK YOU FOR YOUR COOPERATION IN FILLING OUT THIS FORM
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