Download Child Assessment Form Name: Cell# Date___________________

Child Assessment Form
Name:_________________________ Cell#_______________________ Date___________________
Patient is a ______ year-old year old (Race):________________________ (circle) male or female
Who currently resides with (list people in the home).
________________________________________________________________________________
In (city and state) _______________________________ Patient is currently in the _________grade
at (name of school) ____________________. Patient is currently employed by_____________________
as a(Title)______________________for the past (length of time)______________________________.
PRESNTING PROBLEM:
Patient was referred by ____________________________for problems with (please explain in detail)
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Patient is currently experiencing the following symptoms :(Circle all that apply)
Inability to pay attention / keep focus, being easily distracted, being restless and fidgety, being
impulsive, being disorganized, low frustration tolerance, rapid mood swings, being easily stressed, poor
self-esteem, a tendency toward addictive behaviors, family relations issues, oppositional behavior,
education problems, peer conflict.
excessive and /or unrealistic worry that is difficult to control, motor tension (such as restlessness,
tiredness, shakiness and muscle tension), autonomic hyperactivity (such as shortness of breath, heart
palpations, nausea and or diarrhea), hypervigilance (such as feeling on edge, trouble falling or staying
asleep and irritability), social phobia, separation anxiety.
depressed or low mood, suicidal thoughts and or actions, moody irritability, isolation from family or
friends, lack of interest in previously enjoyable activities, low energy, low self-esteem and little or no eye
contact, reduced appetite, increased sleep, poor concentration and indecision, feelings of hopelessness,
worthlessness and inappropriate guilt, unresolved grief issues, mood related hallucinations or delusions.
Other
(please explain)_________________________________________________________________
Please indicate how long patient has been experiencing the above
symptoms.____________________________________________________________________________
BIRTH HISTORY AND DEVELOPMENT
Mother's Age at time of Pregnancy ________________________
Father's Age at time of Pregnancy _________________________
Planned Pregnancy Yes
No
Known use of drugs/alcohol during pregnancy Yes No
Medical Problems/Complications during pregnancy Yes No
Prenatal Care Yes No
Full Term Pregnancy Yes No
Birth Weight ______________________
Complications at delivery for child Yes No
Complications at Delivery for Mother Yes No
Did baby stay more than 5 days in Hospital Yes No
Follow up Child Care Yes No
Post-Partum Depression for Mother Yes No
Follow up care for Mother Yes No
COMMENTS/Explanation of Positive Responses
_____________________________________________________________________________________
Early Development of Child:
Was growth and weight gain normal Yes No
Was there any Failure to Thrive Yes No
Was child colicky Yes No
Early Development of Child:
Age when child:
sat up independently ____________________
crawled ____________________
walked ____________________
spoke words ____________________
spoke sentences ____________________
Age when fully toilet trained
Any concerns about Global Development Delay Yes No
Any current enuresis or encopresis Yes No
COMMENTS/Explanation of Positive Responses______________________________________________
PSYCHIATRIC SOCIAL HISTORY
Were you adopted? Yes No
Did your biological parents separate or divorce during your childhood? Yes No
Loss of parent by death prior to age 18 Yes No
Would you consider your childhood happy average unhappy
Was upbringing (economic class ) lower middle upper
During childhood, were you ever concerned about any form of
Emotional abuse Yes No
Physical abuse Yes No
Sexual abuse Yes No
Education
Current Grade:___________________ Highest grade completed__________________
College Degree_______________________ Graduate Degree______________________________
Special Education
Does child have IEP Yes No
Does child have 504 Plan Yes No
GED earned _______________
Vocational/Trade School ________________
Current Occupation: _______________________________________________
Social
Peer Relationships:
Nature of child's relationship with peers in various settings ____________________________________
Community/Cultural Involvement: _____________________________________________
Does family participate in community activities Yes No
Does the child usually attend religious services Yes No
Is the child involved in community activities Yes No
COMMENTS/Explanation of Positive Responses ______________________________________
Methods of Discipline and Effectiveness: ___________________________________________
Has child been subjected to neglect or physical abuse Yes No
Has child been subject to sexual abuse Yes No
Has child ever been assaulted in the community Yes No
Has child ever witnessed violence or been involved in violent episode Yes No
Relationship leave blank if not applicable
Current Relationship Status:_____________________________________________
Have you ever been divorced? Yes No
Current relationship is poor fair good
Are you currently sexually active? Yes No
Sexual Preferences? Opposite sex Same sex Bisexual
Do you have any concerns or difficulties with sexual functioning? Yes No
Are you pregnant? Yes No Not applicable
Are you trying to get pregnant? Yes No Not applicable
Number of children: ______________________________
Spirituality: none non-practicing active ______________________________
Legal History
Is custody of child with biological family
Yes No
Is child adjudicated dependent Yes No
Past C&Y involvement or services Yes No
Any past Foster Care placement Yes No
Juvenile Justice:
Has the child ever been arrested Yes No
Is the child adjudicated delinquent Yes No
Any past placement in Detention Yes No
Any past placement in a YDC Yes No
COMMENTS/Explanation of Positive
Responses____________________________________________________________________________
____________________________________________________________________________________
PAST PSYCHIATRIC HISTORY
Prior outpatient psychiatric treatment in the past? Yes No
when/where__________________________________________________________________________
Prior outpatient alcohol/substance abuse treatment? Yes No
Prior outpatient treatment was helpful? Yes No
Number of prior psychiatric hospitalizations:_____________________________________
Date of last psychiatric hospitalization: ________________________________________
Number of prior alcohol or substance abuse hospitalizations: _________________________
Date of last alcohol/substance abuse treatment: ____________________________________
Involuntary hospitalizations in past? Yes No
Other levels of Care ________________________________________________________
Prior History of non-suicidal injury (scratching, cutting, burning)? Yes No
Prior History of suicide attempt? Yes No
Number of attempts ______________________
Date of last attempt was: _____________________________
Method of self-harm: _______________________________________________
Attempt resulting in medical hospitalization: Yes
No
Prior History of Aggression or Violence? Yes No
Aggression towards: ____________________________________________________________
Legal charges stemming from aggression: Yes No
Incarceration stemming from aggression: Yes No
Prior Psychiatric medications tried:
_____________________________________________________________________________________
____________________________________________________________________________________
SUBSTANCE USE HISTORY Leave Blank if not applicable
Alcohol: (beer, wine, liquor) Yes
No
Date of last use_______________________ Frequency____________________
Cannabinoids: (marijuana, hashish) Yes
No
Date of last use_______________________ Frequency____________________
Opioids and Morphine Derivatives: (codeine, morphine, Heroin, opium) Yes
No
Date of last use_______________________ Frequency____________________
Stimulants: (cocaine, amphetamines, methamphetamines) Yes
No
Date of last use_______________________ Frequency____________________
Club Drugs: (MDMA, GHB) Yes
No
Date of last use_______________________ Frequency____________________
Dissociative Drugs: (Ketamine, PCP, Dextromethorphan Salvia) Yes No
Date of last use_______________________ Frequency____________________
Depressants: (barbiturates, benzodiazepines) Yes
No
Date of last use_______________________ Frequency____________________
Hallucinogens: (LSD, Psilocybin, Mescaline) Yes
No
Date of last use_______________________ Frequency____________________
Anabolic steroids: (depo-testosterone, anadrol) Yes
No
Date of last use_______________________ Frequency____________________
Inhalants: (huffing, glue, solvents etc.) Yes
No
Date of last use_______________________ Frequency____________________
Intravenous drug use? Yes No
Have you had any difficulties with any of the following issues related to substance use? Yes No
TOLERENCE (increased amount of substance required to obtain initial effect of the drug) Yes No
WITHDRAWAL (symptoms of physiologic or psychological distress upon stopping or reducing the amount
of drug used) Yes No
Consumption exceeds intended amount Yes
Efforts to reduce/control consumption Yes
No
No
Excessive time spent related to substance use and leading to disruption of daily functioning Yes
No
Additional Comments: _________________________________________________________________
FAMILY PSYCHO-SOCIAL HISTORY Parent information
DOMESTIC VIOLENCE SCREENING
Indicate family member addressing questions _________________________________________
Have you been emotionally or physically abused by your partner or someone close/important to you
Yes No
Have you ever been hit, kicked, punched or otherwise hurt by someone close/important to you within
the past year Yes No
Do you feel safe in your current relationship Yes No
Is there a partner from a previous relationship who is making you feel unsafe now Yes No
Was Victim Services information provided to client/family Yes No
COMMENTS/Explanation of Positive Responses
_____________________________________________________________________________________
_____________________________________________________________________________________
SUBSTANCE USE HISTORY Parent or close relative
CIRCLE YES OR NO AND INDICATE FAMILY MEMBER
Alcohol: (beer, wine, liquor) Yes
No __________________________________
Cannabinoids: (marijuana, hashish) Yes
No ____________________________
Opioids and Morphine Derivatives: (codeine, morphine, Heroin, opium) Yes
Stimulants: (cocaine, amphetamines, methamphetamines) Yes
Club Drugs: (MDMA, GHB, Flunitrazepam) Yes
No __________________
No ____________________________
No ___________________________________________
Dissociative Drugs: (Ketamine, PCP, Dextromethorphan Salvia) Yes No___________________________
Depressants: (barbiturates, benzodiazepines Yes
Hallucinogens: (LSD, Psilocybin, Mescaline) Yes
No ________________________________________
No____________________________
Anabolic steroids: (depo-testosterone, anadrol Yes
Inhalants: ( huffing, glue, solvents etc) Yes
Intravenous drug use Yes
No ____________________________
No ___________________________________
No____________________________________________
Have you had any difficulties with any of the following issues related to substance use?
TOLERENCE (increased amount of substance required to obtain initial effect of the drug) Y N
WITHDRAWAL (symptoms of physiologic or psychological distress upon stopping or reducing the amount
of drug used) Y N
Consumption exceeds intended amount Y N
Efforts to reduce/control consumption Y N
Excessive time spent related to substance use and leading to disruption of daily functioning Y N
PSYCHIATRIC SOCIAL HISTORY Parent
Legal Issues Y N explain:_____________________________________________
Prior difficulties with the legal system ever? Yes No explain:__________________________________
Prior incarcerated? Yes No if yes when____________________________
Current legal issues? Yes No explain:_______________________________
Currently on Disability? Yes No explain_____________________________
Currently seeking Disability? Yes No
MEDICAL HISTORY Patient and or family information
Does Patient have any medical concerns?___________________________________________
Report surgeries_______________________________________________________________
Family History of Medical Concerns?_______________________________________________
Are patients Immunizations current? Yes No