Name of Child or Adolescent M/F Today s Date. Birth Date: Age: Name of Person filling out form (Parent or Adolescent): REASON FOR SEEKING TREATMENT
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1 1 Jill Jacobson Ph.D. Washington State Psychologist License # Dayton Suite A-3 Edmonds, WA (206) Child or Adolescent History Information Form Name of Child or Adolescent M/F Today s Date Birth Date: Age: Name of Person filling out form (Parent or Adolescent): REASON FOR SEEKING TREATMENT Please briefly explain your reason for seeking therapy for your child or adolescent at this time: Please list any stressors in your child s or adolescent s life (or the family member s lives) at this time that may contribute to the issues. Some common contributing factors are school stresses, peer problems, chronic illness, stressful family relationships, financial stresses, parent s work or career stresses, parenting conflicts, deaths of loved ones or pets, home or school moves, alcohol or drug use, affairs, physical or emotional abuse, behavior problems, legal issues, divorce, etc.:
2 Please list things you have already tried to help solve your child s or adolescent s issues so far: MEDICAL INFORMATION FOR YOUR CHILD OR ADOLESCENT Name of the Primary Care Physician: Name of Medical Practice Address Street City, State, Zip Code Office Phone #: ( ) Fax #: ( ) May I contact the physician if needed? Please initial: Yes No List any major health problems for which your child or adolescent currently receives treatment: List any history of health problems or surgeries your child or adolescent has experienced? Were there any health problems at birth, infancy, or childhood, or adolescence? List any medications or supplements with dosages your child or adolescent is currently taking: Name of Medication Dosage Taken how often What the Medication Treats SYMPTOM CHECKLIST Following are checklists of a variety of behaviors and symptoms about your child or adolescent. I would appreciate it if you would take the time to fill these checklists out completely. This information will be extremely useful to me in my completing a more thorough and comprehensive assessment of your child or adolescent s issues. It will also enable me to shorten the initial history interview and more quickly develop an individualized treatment plan tailored especially for your child or adolescent. If there are areas you do not feel comfortable answering on paper, just let me know. Please check any of the following items that may pertain to your child or adolescent more often than not or that you have concerns about. You can also add comments in the spaces.
3 FEELINGS OF WELL-BEING My child or adolescent generally feels worthwhile and likeable Respects self Feels close to people Cares about others Generally seems happy Enjoys life and friends Feels he/she is accomplishing something Often seems to have fun in life Feels hopeful Faith plays a part in his/her life Feels the future looks bright Believes problems can be solved Has a best friend Feels a respect and reverence for life Other positive feelings? SADNESS Often feeling sad, down, depressed or hopeless Little interest or pleasure in doing things Poor appetite or overeating noticeable weight change or failure to gain weight Trouble falling asleep, staying asleep, or sleeping too much Often acts slowed down or sped up Frequently seems tired or has little energy Feels excessively worthless or guilty Difficulty concentrating on things or trouble making decisions Thoughts of death with or without a plan Other depression symptoms? WORRIES Difficulty controlling worries Gets tired easily Irritable Muscle tension Difficulty falling asleep Waking up in the middle of the night Waking up in the early morning Difficulty concentrating Feeling keyed up or restless Significant Anxiety Worrying about social events Worries about looking stupid or being embarrassed Difficulty having social conversations Avoids being center of attention Other Worries? PANIC Attacks of sudden intense fear Pounding or racing heartbeat Shakiness or trembling Shortness of breath Chest pain Nausea or abdominal distress Feeling dizzy or lightheaded Feeling things are unreal or like a dream Fear of losing control or going crazy Numbness, tingling, chills, or sweating Choking or smothering sensation Fear of dying Other Panic symptoms?
4 CONCENTRATION Fails to give close attention to details or often makes careless mistakes Difficulty staying focused on tasks homework, conversations, chores Often doesn t seem to listen when spoken to mind seems elsewhere Doesn t follow through on instructions fails to finish homework or chores Difficulty organizing tasks and activities notebook messy, room disorganized Procrastinates on things homework, chores, lengthy reports, etc. Often looses things necessary for tasks. Homework, books, coats, cell phone, Easily distracted by things or events often by own unrelated thoughts Often forgetful in daily activities appointments, tests, chores, etc. ACTIVITY LEVEL Often fidgets with hands, taps legs, or squirms in his/her seat Often leaves seat where remaining seated is expected church, classroom, etc. Runs or climbs about in situations in which it is inappropriate Difficult to play quietly Often On the Go as if driven by a motor Others see as hard to keep up with Often talks excessively Motor mouth Often blurts out things completes other s sentences or jumps the gun in talking Difficulty waiting for his or her turn in conversations or while waiting in line Frequently interrupts or intrudes on others Conversations, activities, games, etc. ANGER Trouble controlling anger Looses temper frequently Friends often get angry toward him/her Argues with others Does things deliberately to annoy people Feels like getting back at people Sometimes hurts other people or mean Often feels angry or resentful Often blames others Start verbal or physical fights Shouts or yells often Throws, breaks or smashes things Frequently Irritable Other anger issues? BEHAVIOR PROBLEMS Steals Lies Runs away from home Threatens or intimidates others Physically cruel to animals Destroys other s possessions Destroys his/her own possessions Sometimes gets in rages Stays out all night without permission Has used a weapon Has forced others to be sexual Has set fires Been involved with the law Alcohol or drug use concerns Other concerns?
5 TRAUMATIC EVENTS Experienced a traumatic event Has suffered abuse now or in past Memories of the event are very upsetting Wetting the bed Nightmares or bad dreams Avoid things or feelings about the event Can t remember parts what happened Startles easily Can t stop thinking about the trauma Difficulty having pleasure in anything Feels numb inside Feels disconnected from others Often feels helpless Feels guilty or hopeless What traumatic events have happened? OBSESSIONS / COMPULSIONS Can t stop thinking about some things Can t stop doing some things Excessive hand washing Doing things too slowly or perfectly Excessive checking Difficulty making decisions Routines or rituals she/he can t stop Excessive cleaning Do things to prevent thoughts / problems Knowing actions are irrational can t stop Need things to be in order Feels he/she will accidentally hurt others Avoids things because of obsessions Sexual Compulsions Other specific obsessions / compulsions? FEARS Afraid of Fear of animals or objects Uneasiness of crowded places Afraid to travel Afraid to be alone Unreasonable fear of something Fear of animals Fearful of people Uncomfortable in some social situations Avoiding fearful things, objects or places Intense anxiety at times Fearful of one or more person(s) Afraid of going to work Scared to be in a relationship Other fears? HEALTH CONCERNS Concerned about his/her health Stomachaches Headaches Pains in heart or chest Backaches Sore muscles Dizziness Fear of having a serious disease Frequent doctor visits Chronic pain or unexplained pain Feeling weak or often tired Fear of death Any Chronic Illnesses? Specific health Concerns at this time?
6 RELATIONSHIPS WITH FAMILY Close to mom Close to dad Gets homesick often Stays overnight at friends Close to grandparents Feels compassion for others Does nice things for family members Remembers other s birthdays Suffered a loss or death Feels close to a pet Feels bad when hurts other s feelings Thinks of others over his/her self Close to step-parent (if applicable) Close to siblings Other relatives? RELATIONSHIP PROBLEMS Struggles with healthy relationships Often feels lonely Frequently disappointed by relationships Often doesn t feel close to others Lots of conflict in relationships Has few friends Often feels critical of others Feel others dislike him/her Feels inferior to others a lot Often self-conscious Extremely shy or too sensitive Not close to either parent Feels most people cannot be trusted Doesn t have a best friend or group Other Concerns? SCHOOL & CLASSROOM Has trouble getting homework done Doesn t turn in daily homework Child misses a lot of school Disciplined by teacher or principal Special education Doesn t get along with other students Lonely in school Trouble using the public bathrooms Difficulty at lunch or recess Poor academic grades Doesn t like school or doesn t like to go Frequently goes to nurses office Learning difficulties or IEP or 504 plan School suspension or expulsion Other issues? DAILY FUNCTIONING PROBLEMS Has trouble sleeping Takes too long of naps during the day Overeats Toileting accidents or wetting the bed Doesn t eat enough Doesn t get enough exercise Exercises too much Binges on food sometimes Throws up after eating Often has constipation or diarrhea Risk-taking behaviors Hurts or cuts on self Thinks of dying or suicide Mood swings Up and Down Moods Other problems?
7 HISTORY & DEVELOPMENT 1. Child Birth and Infancy: Age of Mother at Birth of Child Age of Father Length of Pregnancy Length of Labor Birth Weight Breastfed If so, for how long Any complications with pregnancy, delivery or birth? Any problems during the first year of life? (For example, sleep difficulties, colicky, didn t want to be held, feeding problems, allergies, ear infections, etc.) 2. Toddler and Preschool Years: Age when child: Spoke First Word Sentences Toilet Trained Crawled Walked Ran Any problems with walking or coordination, unclear speech, eating problems, underweight or overweight, sleep problems, excessive tantrums, excessive activity, crying, behavior problems, aggression, fussiness, etc.? 3. School Years and Educational History: Age when first attended Kindergarten Any problems with school grades, teachers, peers, learning problems, difficult experiences? Any problems with learning challenges or disabilities? Does your child have a 504 or IEP Plan? What grade is your child in now? Name of school? Where is your child or adolescent after school? 4. Social Development: Does your child or adolescent make or keep friends? Best friend or group? Major support system for your child or adolescent? Has child or adolescent experienced any physical or sexual abuse, emotional abuse or neglect, or any CPS involvement? 5. Overall Development: Any concerns regarding: Gross Motor Skills (running, throwing ball, bicycling ) Fine Motor Skills (coloring, drawing writing scissor use ) Speech & Language Skills (pronunciation, vocabulary ) Self-Control Skills (impulse control, delay of gratification ) Self-Concept (opinion of him or herself, abilities, worth..)
8 Cognitive Skills (memory, comprehension, knowledge ) 6. Please list any Mental Health Treatment your child or adolescent has had in the past including therapists, psychologists, psychiatrists, psychiatric hospitalizations, substance abuse treatment, etc.: 7. Please list the strengths of your child or adolescent: 8. Please list your child s or adolescent s favorite Activities / Hobbies / Ways they Relax: 9. What is your child or adolescent most looking forward to? FAMILY HISTORY Please check any of the following that your child or adolescent s biological relatives may have experienced: Depression Hyperactivity (ADHD) Alcohol Problems Anxiety Bipolar Disorder Drug Problems Mood Swings Attempted Suicide Completed Suicide Panic Attacks Obsessive-Compulsive Dis Tic Disorder Learning Disabilities Problems with the Law Jail time Heart Disease Diabetes Obesity High Blood Pressure Cancer Thyroid Problems Physical Abuse Emotional Abuse Neglect Sexual Abuse Seizures Schizophrenia Other: Thank you very much for patience in taking the time to answer all of these questions about your child or adolescent. It really helps me do a more comprehensive evaluation. If you have any questions at all about this questionnaire, please feel free to bring it up with me at our first session. Is there anything else you would like me to know that was not on this questionnaire? Thank you!
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Francine Grevin, Psy.D. Licensed Clinical Psychologist PSY South Main Plaza, Suite 225 Telephone (925) CHILD HISTORY FORM
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