CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake)

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CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake), LLC 2383 University Ave West, Suite 200 Saint Paul MN 55114 Phone: 651-644-4100 Fax: 651-644-4100 Date: Form Completed By: Relationship to the client: CLIENT INFORMATION Child s Last Name Child s First Name Child s Middle Name Street Address City, State Zip Code appropriate box for address: house apartment residential facility homeless Name of Parent/s or Guardian/s: Home Phone Number Cellular Phone Number Alternate Phone Number OK to leave message? OK to leave message? OK to leave message? Yes No Yes No Yes No Race ( all that apply): American Indian/Alaska Native Tribe: Asian ( Chinese Hmong Japanese Korean Laotian Vietnamese Other ) Black/African American ( Ethiopian Somalian Other ) Native Hawaiian or Other Pacific Islander White Other Ethnicity: Hispanic/Latino/a Not Hispanic/Latino/a Primary Language: English Religion: Other Languages Spoken: Cultural considerations for treatment: REFERRAL INFORMATION: Who referred you to your appointment today? Child/Adolescent Self-Report Form Page 1

REASONS FOR WANTING SERVICES Please all that apply: ADHD Grief/Loss/Death Panic Attack Sleep Problems Attachment Issues Health Problems Parenting Issues Stress Alcohol Issues Hearing Voices Phobia/s Suicidal Thoughts Anger Problems Help Finding Resources Physical Abuse Suicide Attempt/s Anxiety HIV/AIDS Physical Pain Trauma Body Image/Weight Issues Hyperactivity Psychiatric Hospitalization Other: Bingeing and/or Overeating Identity Issues Purging (Throwing up) Communication Issues Inattention Relationship Concerns Developmental Delay/s Learning Problems Restricting Food Depression Legal Problems Sadness Disruptive Behavior Memory Problems Schizophrenia Eating Disorder Mood Swings Self-Esteem Issues Drug Issues Obsessions Sexual Abuse/Trauma Fetal Alcohol Syndrome Out of Home Placement Sexuality Concerns TYPE OF SERVICES REQUESTED: please all that apply Individual Therapy Family Therapy Children s Therapeutic Services DBT Therapy Medication Management/ Psychiatry and Supports (CTSS) Psychological Testing Group Therapy CHILD/ADOLESCENT CURRENT MEDICATIONS (list more on separate page if necessary): Prescribed by: Current Medication For What Condition? Dose Frequency Date Side Effects/Comments Started 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Past Medication For What Condition? Past Medication For What Condition? 1. 6. 2. 7. 3. 8. 4. 9. 5. 10. Medication Allergies: Child/Adolescent Self-Report Form Page 2

FAMILY MEDICAL/PSYCHOLOGICAL HISTORY CHILD/ADOLESCENT HISTORY: please all that apply Alcohol/Drug Abuse Domestic Abuse Hyperactivity Psychiatric Hospitalization Allergies Eating Disorder Inattention Schizophrenia Anxiety Epilepsy/Seizures Learning Problems Sexual Abuse Autism Fetal Alcohol Syndrome Legal Problems Stomachaches Bedwetting Foster Care (past or present) Manic/Bipolar Disorder Suicide/Attempt Blood Clot/Stroke Headaches Mental Retardation Surgery/ies Cancer Heart Attack/Disease Panic Attacks Tuberculosis Depression HIV/AIDS Physical Pain Other: Diabetes High Blood Pressure Physical Abuse Please Describe Any Issues Checked Above: MOTHER AND MOTHER S SIDE OF THE FAMILY: Check here if history is unknown Alcohol/Drug Abuse Diabetes High Blood Pressure Physical Pain Allergies Domestic Abuse Hyperactivity Physical Abuse Alzheimer s Eating Disorder Inattention Psychiatric Hospitalization Anxiety Epilepsy/Seizures Learning Problems Schizophrenia Autism Fetal Alcohol Syndrome Legal Problems Sexual Abuse Bedwetting Foster Care (past or present) Manic/Bipolar Disorder Stomachaches Blood Clot/Stroke Headaches Mental Retardation Suicide/Attempt Cancer Heart Attack/Disease Panic Attacks Surgery/ies Depression HIV/AIDS Personality Disorder/s Tuberculosis FATHER AND FATHER S SIDE OF THE FAMILY: Check here if history is unknown Alcohol/Drug Abuse Diabetes High Blood Pressure Physical Pain Allergies Domestic Abuse Hyperactivity Physical Abuse Alzheimer s Eating Disorder Inattention Psychiatric Hospitalization Anxiety Epilepsy/Seizures Learning Problems Schizophrenia Autism Fetal Alcohol Syndrome Legal Problems Sexual Abuse Bedwetting Foster Care (past or present) Manic/Bipolar Disorder Stomachaches Blood Clot/Stroke Headaches Mental Retardation Suicide/Attempt Cancer Heart Attack/Disease Panic Attacks Surgery/ies Depression HIV/AIDS Personality Disorder/s Tuberculosis SIBLINGS (if applicable): N/A Check here if history is unknown Alcohol/Drug Abuse Diabetes High Blood Pressure Physical Pain Allergies Domestic Abuse Hyperactivity Physical Abuse Alzheimer s Eating Disorder Inattention Psychiatric Hospitalization Anxiety Epilepsy/Seizures Learning Problems Schizophrenia Autism Fetal Alcohol Syndrome Legal Problems Sexual Abuse Bedwetting Foster Care (past or present) Manic/Bipolar Disorder Stomachaches Blood Clot/Stroke Headaches Mental Retardation Suicide/Attempt Cancer Heart Attack/Disease Panic Attacks Surgery/ies Depression HIV/AIDS Personality Disorder/s Tuberculosis Child/Adolescent Self-Report Form Page 3

DRUG/ALCOHOL USE/ABUSE please appropriate boxes Alcohol Never Used Currently Use Used in Past Age at First Use: Sedatives Never Used Currently Use Used in Past Age at First Use: Crack Cocaine Never Used Currently Use Used in Past Age at First Use: Club Drugs Never Used Currently Use Used in Past Age at First Use: Cocaine Never Used Currently Use Used in Past Age at First Use: Hallucinogens (i.e., LSD) Never Used Currently Use Used in Past Age at First Use: Heroin Never Used Currently Use Used in Past Age at First Use: Inhalants Never Used Currently Use Used in Past Age at First Use: Marijuana Never Used Currently Use Used in Past Age at First Use: Methadone Never Used Currently Use Used in Past Age at First Use: Opiates Never Used Currently Use Used in Past Age at First Use: Prescription Drugs Never Used Currently Use Used in Past Age at First Use: PCP Never Used Currently Use Used in Past Age at First Use: Stimulants (i.e., Never Used Currently Use Used in Past Age at First Use: methamphetamine) Other: Currently Use Used in Past Age at First Use: Other: Currently Use Used in Past Age at First Use: EDUCATIONAL HISTORY Name of School: Public Private Grade: Teacher: Current: Past Year: Attendance good average poor Attendance good average poor Quality of work good average poor Quality of work good average poor Homework behavior good average poor Homework behavior good average poor In school behavior good average poor In school behavior good average poor Friendships good average poor Friendships good average poor Has your child/adolescent ever: Repeated a grade? No Yes Grade: Received Special Education Services? No Yes When: Been diagnosed with a learning disability? No Yes When: Been diagnosed with ADHD? No Yes When: Had a previous Individualized Education Plan (IEP)? No Yes When: Does your child/adol. have a current IEP? No Yes Describe your child s academic strengths and weaknesses: Motivational Problems: Behavior Problems: Child/Adolescent Self-Report Form Page 4

EMPLOYMENT HISTORY (if applicable) Please list any current or previous jobs that adolescent has held including position, length of time at job, reason for leaving, and any other pertinent information: How is your family supported financially? LEGAL HISTORY Has your child/adolescent ever been arrested or in trouble with the law? No Yes Please explain: Is your child/adolescent currently on probation? No Yes Has the child/adolescent s mental health treatment been court ordered? No Yes CURRENT LEVEL OF FUNCTIONAL IMPAIRMENT (circle corresponding level) (0 = no impairment, 5 = moderate impairment, 10 = severe impairment) Relationship with caregiver 0 1 2 3 4 5 6 7 8 9 10 Relationship with family 0 1 2 3 4 5 6 7 8 9 10 Friendships/Peer Relationships 0 1 2 3 4 5 6 7 8 9 10 Job/School Performance 0 1 2 3 4 5 6 7 8 9 10 Cognitive/Learning 0 1 2 3 4 5 6 7 8 9 10 Hobbies/Interests 0 1 2 3 4 5 6 7 8 9 10 Physical Health 0 1 2 3 4 5 6 7 8 9 10 Activities of Daily Living 0 1 2 3 4 5 6 7 8 9 10 Eating Habits 0 1 2 3 4 5 6 7 8 9 10 Sleep 0 1 2 3 4 5 6 7 8 9 10 Ability to Control Temper 0 1 2 3 4 5 6 7 8 9 10 Notes: Child/Adolescent Self-Report Form Page 5

YOUR CHILD S CURRENT PROVIDER(S) AND PROFESSIONAL(S) PRIMARY CARE PHYSICIAN PSYCHIATRIST CASE MANAGER Length of time services received: Length of time services received: Length of time services received: PROBATION OFFICER CPS WORKER SCHOOL COUNSELOR/SW Length of time services received: Length of time services received: Length of time services received: OTHER OTHER OTHER Length of time services received: Length of time services received: Length of time services received: PAST PROVIDERS AND PROFESSIONALS (Include Psychologists, Psychiatrists, Social Workers, etc) TYPE OF PROVIDER: TYPE OF PROVIDER: TYPE OF PROVIDER: When services were received: When services were received: When services were received: Child/Adolescent Self-Report Form Page 6

I certify that I have answered these questions to the best of my knowledge. Parent/Guardian Signature Date CLINICIAN NOTES (clarifications, follow up, etc.) Clinician Date Cosignatory Date Child/Adolescent Self-Report Form Page 7

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