Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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