Download Confidential Family History

ROCKLAND I.D.T CONFIDENTIAL
Student / Family History Information
Student’s Name:
Address:
Apt #:
City:
Home Phone #:
M /F
Date of Birth:
Student’s Social Security # _ _ _ / _ _ /_ _ _ _
Current Medical Insurance:
State:
Zip:
Insurance ID Number:
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) :
Was the delivery:
normal/vaginal
C-section
take any medication,
smoke cigarettes, drink
Birth weight:
alcohol, use drugs
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:
1
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: ______________________________________
Where were you born? _________________________
Date of Birth:____________________
Where were you raised? _________________________
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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
3
Hospitalization Dates
Outpatient / Clinic
Reason for treatment
Is your child on medication NOW or in the PAST?
Therapist Name
Dates of treatment
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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