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Peace Of Mind Psychological Services, LLC Client History Form Date: ______________________________ Name: ______________________________ D.O.B.: ____________________ Address: ______________________________ Age ____________________ ______________________________ Email: ____________________ Home Phone: Emergency Contact: Cell Phone: ______________________________ ____________________ Phone Number: ______________________________ ____________________ Patient Communication Preferences: Our office may need to contact you to schedule and/or reschedule appointments, to schedule follow-up visits and other such administrative issues. To ensure that your privacy is maintained to the fullest extent possible, please select the method by which our office can contact you. Home phone- Leave message? Yes________ No_________ Cell phone- Leave message? Yes________ No_________ Work phone- Leave message? Yes________ No_________ Email? Yes________ No_________ PARENT/GUARDIAN INFORMATION Names Relation to child Contact Number ______________________ _____________________ ______________________ _____________________ ______________________ _____________________ __________________________ __________________________ __________________________ If parents are divorced: Who is the “custodial” parent? ________________________________ Frequency of visitation with “non-custodial” parent? __________________________________ SIBLINGS Name Age _________________________________ _________________________________ _________________________________ Primary Residence ___________________ ___________________ ___________________ __________________ __________________ __________________ 9810-A Medlock Bridge Road Suite 103-A John’s Creek, Georgia 30097 1|Page Peace Of Mind Psychological Services, LLC Quality of Family Relationships: Include all people who live in the home Name Age Relationship Quality of Relationships (poor, fair, good) ___________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ ___________________________________________________________________________________ What concerns brought you in today? ______________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ MENTAL HEALTH HISTORY Has your child ever been diagnosed with a mental health diagnosis? If so, what? ______________________________________________________________________________ Has your child ever received mental health treatment? Counselor Name Dates Reason for Treatment ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Psychological Evaluation Date Diagnosis (es) Name of Assessor _________________________________________________________________________________ _________________________________________________________________________________ Psychiatric Hospitalization Date Reason for Treatment _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Name of Psychiatrist (if applicable) _________________________________________________________________________________ Name of current psychiatric medications _________________________________________________________________________________ Name of past psychiatric medications _________________________________________________________________________________ Is there any history of self-injury (i.e., hitting, biting, cutting) or suicidal behavior? __________________________________________________________________________________ 9810-A Medlock Bridge Road Suite 103-A John’s Creek, Georgia 30097 2|Page Peace Of Mind Psychological Services, LLC Family History of Mental Health Problems (check all applicable areas) Mother Father Aunt Uncle Cousins Grandparents Anxiety Depression Bipolar Disorder Schizophrenia ADHD Drugs/Alcohol Eating Disorder Post-Traumatic Stress Disorder Behavioral Checklist 0-Not a Problem, 1-Mild Difficulty (Occurs less than weekly), 2-Moderate (Occurs at least 1-2 times a week), 3-Severe Problem (Occurs several times a week) Behavior Severity Behavior Severity Behavior Severity Alcohol Abuse 0, 1, 2, 3 Irritability 0, 1, 2, 3 Loses Things 0, 1, 2, 3 Drug Abuse 0, 1, 2, 3 Destruction to property 0, 1, 2, 3 Poor Organizational Skills 0, 1, 2, 3 Social/Relational 0, 1, 2, 3 Lying 0, 1, 2, 3 Easily Distracted 0, 1, 2, 3 Academic 0, 1, 2, 3 Run Away 0, 1, 2, 3 0, 1, 2, 3 Physical Aggression 0, 1, 2, 3 Steals 0, 1, 2, 3 Difficulty communicating clearly Impulsive Verbal Aggression Bullying 0, 1, 2, 3 0, 1, 2, 3 Inattention Fidgety 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 Losing temper easily Argumentative Defiant 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 Fails to finish things Talks excessively Forgetfulness 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 Easily Annoyed by others Difficulty sleeping 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 Self-harm attempts 0, 1, 2, 3 Nightmares 0, 1, 2, 3 0, 1, 2, 3 Separation anxiety 0, 1, 2, 3 Poor appetite Lack of physical boundaries 0, 1, 2, 3 0, 1, 2, 3 Interrupts others/Blurts out Hears voices that are not there Sees things that are not there Fear/Phobia Excessive worry Tired/Fatigued Unpredictable Moods Sadness Low self-esteem Thoughts of selfharm Thoughts of death 0, 1, 2, 3 0, 1, 2, 3 Heart racing Sexual behavior problems 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 0, 1, 2, 3 How would you describe your child? __________________________________________________ ______________________________________________________________________________ 9810-A Medlock Bridge Road Suite 103-A John’s Creek, Georgia 30097 3|Page Peace Of Mind Psychological Services, LLC What are his/her strengths?_________________________________________________________ ______________________________________________________________________________ What activities does he/she enjoy? ___________________________________________________ Participate in?_____________________________________________________________ How does your child get along with peers? ______________________________________________ ______________________________________________________________________________ Does your child have any history of abuse? (i.e., sexual, physical, emotional) If so give specific details (i.e., dates, nature of abuse, was there legal involvement?) __________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Has your child ever witnessed any domestic violence, violence which led to injury or death, or loss? ______________________________________________________________________________ ______________________________________________________________________________ How does your child manage stress/emotional distress? ____________________________________ ______________________________________________________________________________ Additional comments _____________________________________________________________ ______________________________________________________________________________ MEDICAL HISTORY Pediatrician_____________________________________________________________________ Current Medical Problems (including allergies) __________________________________________ ______________________________________________________________________________ Past Medical Problems (including surgeries) _____________________________________________ ______________________________________________________________________________ Current Medication Dosage Frequency Prescribed by Reason prescribed ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 9810-A Medlock Bridge Road Suite 103-A John’s Creek, Georgia 30097 4|Page Peace Of Mind Psychological Services, LLC Has your child ever sustained a head injury? _____________________________________________ How is your child’s appetite? ________________________________________________________ How is your child’s sleeping? ________________________________________________________ DEVELOPMENTAL HISTORY What was the length of the pregnancy? __________________ Weight at birth? ____________ Were there any complications during the pregnancy with your child?___________________________ ______________________________________________________________________________ Was there any maternal drug or alcohol abuse? __________________________________________ Developmental milestones (provide specific ages in months) Crawl_______ Walk______ First words_____ Combined Words______ Toilet Trained________ Did you have any concerns about your child as a toddler (i.e., seeing, hearing, social interactions, learning, sleeping, eating?) _________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ EDUCATIONAL Current school __________________________________________ Grade __________________ Current grades __________________________________________________________________ Academic strengths _______________________________________________________________ Academic Weaknesses ____________________________________________________________ Has your child ever been retained? Is so when ___________________________________________ Does your child receive any academic accommodations (IEP, 504 plan, EIP) ______________________ ______________________________________________________________________________ Any other services (i.e., speech, occupational, physical therapy) ______________________________ ______________________________________________________________________________ 9810-A Medlock Bridge Road Suite 103-A John’s Creek, Georgia 30097 5|Page Peace Of Mind Psychological Services, LLC Behavioral Concerns (including suspensions and detentions) _________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SPIRITUAL Is faith/religion meaningful in your life? ________________________________________________ If yes, do you have a faith/church affiliation?_____________________________________________ ALCOHOL AND DRUG HISTORY Is your child/teen currently using drugs or alcohol? If so, please give specific details __________ ______________________________________________________________________________ ______________________________________________________________________________ Is there any history of substance abuse treatment? _______________________________________ ______________________________________________________________________________ ______________________________________________________________________________ LEGAL HISTORY Has your child ever been arrested? ___________________________________________________ Charge/Date ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Current probations/terms __________________________________________________________ Past probation/terms _____________________________________________________________ Any other legal problems? __________________________________________________________ Thank you for completing this form and I look forward to working with you. Dr. Brianna Gaynor 9810-A Medlock Bridge Road Suite 103-A John’s Creek, Georgia 30097 6|Page