1 General Information2 Parent Information3 Siblings and Others in Home4 Information on Child 5 Academic History and Social Relationship6 Family history7 Your feedback Fields marked with * are compulsory.Child’s Name:*Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Completed by:*MotherFatherToday’s Date:*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Mother's Name:*Address:* Street Address City ZIP / Postal Code Home Phone:Cell Phone:*Email:* Occupation:*Father’s Name:*Address (only if different from above): Street Address City ZIP / Postal Code Home Phone:Cell Phone:*Email:* Occupation:*OIB and name of parent to whom the invoice will be issued*Parents’ Relationship Status:*MarriedNever MarriedSeparatedDivorcedParteneredWidowedIf divorced, who is the legal guardian? Siblings (including step-siblings and half-siblings):1. NameAgeGenderMaleFemale2. NameAgeGenderMaleFemale3. NameAgeGenderMaleFemaleOthers in the home (grandparents, cousins, family friends): 1. NameAgeGenderMaleFemale2. NameAgeGenderMaleFemale3. NameAgeGenderMaleFemale Significant Life Events in the Last Two Years: Death of a loved one Move/School change Financial problems for the family Parental remarriage/ new step-siblings Trauma (violence, natural disaster, car accident, etc) Birth of a new sibling Divorce/Separation Medical Problems for any family member Other Legal problems for the family (assault, DUI, etc) Child’s Strengths or Abilities Academics/grades Group involvement (clubs, organizations) Sense of humor Sport Care for others Creative (art or music, etc) Other Religious involvement Current Concerns about Your Child Behavior at home/school Suicidal thoughts Anger/Irritability Health Sensitive to touch, sound, light, motion Mood Academic performance/grades Difficulty paying attention Drugs/alcohol Eating Sleeping Peer relationships Frequent worries/shyness Sexual behavior Comments:Is there a history of any previous treatment or any evaluations?NoYesIf so, when and by whom?Educational evaluation:Psychological evaluation:Outpatient therapy:Hospitalization(s):Does your child take medication?NoYesIf so, please list medication(s) and dosage(s):Who is the prescribing physician?Child’s Medical History Medical problems during pregnancy Maternal drug or alcohol use during pregnancy Complications during birth (ex. Emergency C-section, low oxygen, etc) Health problems as a newborn or toddler Frequent ear infections Asthma or allergies Head injuries/concussions/seizures/fevers over 104 degrees Serious accidents/hospitalizations Surgeries Problems with eating or sleeping Stayed in neonatal intensive care Premature birth (if so, weight at birth: How long stayed in neonatal intensive care?Weight and gestional age for premature birth:Child’s PhysicianComments:Child’s Developmental History (Problems with…? ) Sitting up Walking Talking Toileting Bedwetting Writing letters or using scissors Reading or letter identification Physical coordination (running, jumping, climbing) Responding to discipline or behavior management Anger/temper tantrums Fears Sexual play Other: Child’s Academic HistoryCurrent School/KindergartenGrade (for schools only):Has your child…? Repeated a grade Skipped school Been suspended Been expelled Stopped doing homework Been bullied by others Been aggressive at school Received any special services (OT, PT, Reading, Speech, Self-Contained, etc) Child’s Social RelationshipsDoes your child have a friend or friends outside the family?YesNoDo you know them?YesNoDo his/her friends tend to be:OlderYoungerAbout the same ageHow well does your child get along with others? Family HistoryHas anyone in your family struggled with (treated or untreated): Depression or Bipolar Disorder Anxiety Learning problems (reading, math, spelling) Attention problems Excessive alcohol or drug use Sexual abuse Physical abuse Suicide attempts or completed suicide Do you have any other concerns about your child? What do you hope to accomplish by working with me?How did you hear about me and my services?
