Child History Form

Patient last name

Patient first name

Presenting Problem

What are the symptoms of concern?

When do they occur and how often?

What has been done to treat the symptoms? What types of procedures, programs, or services have you sought?

How successful have previous treatments been?

Family and home life

Is the patient living with someone other than his/her biological parents?

What is the marital status of biological parents

If biological parents are divorced or separated, please specify custody and visitation schedule in effect to include the schedule for school weeks, summers, and holidays.

Please describe the relationship with the patient's parents - is there unanimity in parenting? If not, what are the major differences?

Please list all individuals living with the patient along with their ages.

Describe the relationship of the patient with adults in the household.

What disciplinary techniques are used at home?

Describe the residence in which the patient lives (ie; how many bedrooms etc...)

Does the patient have their own bedroom?

If "no" to the previous question, with whom is the bedroom shared?

Are there any psychological problems of concern among members of the household ?

If "yes" to the previous question, what, if any, treatment is being received?

What is the work schedule of the parents/guardians?

Academic

Has the patient ever been before the local screening or child study committee at school?

If "yes" to the previous question, what were the results?

Is the patient experiencing problems at school?

If "yes" to the previous question, are the symptoms occurring at home different than at school?

What have teachers at school said about the patient's behavior?

Has the patient ever been suspended or otherwise disciplined because of school concerns?

Is the patient involved in any preschool or afterschool care?

If "yes" to the previous question, are their any behavioral issues observed?

If known, please list approximate scores on any school based standardized testing such as the COGAT, NNAT, DRA, PSAT, SAT, and so on.

Generally, how does the patient do on standardized testing?

Is the patient in special education classes?

If "yes" to the previous question, can we please have a copy of the IEP or 504 plan?

List the schools the patient attended, the years of attendance, and generally how the patient performed academically and behaviorally.

Medical & Developmental

List any illnesses, surgeries, or treatment interventions of any sort involving the patient. List the dates they occurred and any other pertinent information.

If applicable, please list any current or past medication(s) the patient has taken, to include estimated time period(s).

Please describe how the patient gets along with peers. Have there been changes over the years? If so, please describe the changes.

Has the patient ever been exposed to traumatizing events or circumstances (such as accidents, abuse, and so on)?

If "yes" to the previous question, please list them along with general dates.

Legal

Has the patient ever been exposed to traumatizing events or circumstances (such as accidents, abuse, and so on)?

If "yes" to the previous question, please specify what they are including the court of jurisdiction, the charges involved, the name of any attorney(s) involved with the child and the family including a guardian ad litem, the name of any CASA worker,

Is there any court ordered therapy or testing being requested currently?

If "yes" to the previous question, please list any deadlines.

Summary

What goals do you hope to attain as a result of the therapy and / or assessment services being offered?

Please list any additional comments or concerns that were not addressed above.

Signature and dates

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Date signed

info@associatedclinical.com

703 - 569 - 8731

Child History Form

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