Child and Youth Background Information

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Transcription:

Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that apply: Substance Frequency Amount Tobacco Caffeine Alcohol Cocaine/ Crack Ecstasy Heroin Inhalants Methamphetamines Pain Killers PCP/ LSD Steroids Tranquilizers Marijuana Has your child had withdrawal symptoms when trying to stop using any substances? If yes, please describe: Has your child ever had problems with work, relationships, health, the law, etc. due to his/her substance use? If yes, please describe: PREVIOUS MENTAL HEALTH TREATMENT If yes: Dates of Treatment: From To Provider/Program 2012 Advance Potential Psychological Services Child and Youth Background Info Page 1 of 5

Type of Treatment: Outpatient Counseling Psychiatric Hospitalization Self-help/Support Groups Medication (mental health) Drug/Alcohol Treatment Primary Care Physician & Medical Care Current Physician: Physician Address: Primary Care Physician Phone #: ( ) Fax #: ( ) Emergency Contact: Medical: MEDICAL INFORMATION Date of last physical exam: Has your child experienced any of the following medical conditions during his/her lifetime? Allergies Asthma Headaches Stomach Aches Chronic Pain Surgery Serious Accident Head injury Dizziness/fainting Meningitis Seizures Vision problems High Fevers Diabetes Hearing problems Miscarriage Sexually Transmitted Disease Abortion Sleep Disorder Other (please list): Please list any CURRENT health concerns: Current prescription medications: Medication Dosage: Date First Prescribed: Prescribed By: Current over-the-counter medications (including vitamins, herbal remedies, etc.): Please list any allergies and/or adverse reactions to medications: 2012 Advance Potential Psychological Services Child and Youth Background Info Page 2 of 5

SCHOOL INFORMATION Current grade/placement: This year s school grades: Excellent Good Fair Poor Past school grades: Excellent Good Fair Poor This year s school behavior: Excellent Good Fair Poor Past school behavior: Excellent Good Fair Poor Has your child had any of the following difficulties at school? Suspension Incomplete homework Learning problems Referrals or detentions Poor grades Teased or picked on Speech problems Attendance problems Gang influence Does your child have an after-school provider? Yes No If so, who? Has your child ever repeated a grade? Skipped a grade? Yes No If yes, which one(s)? Has your child ever received Special Education services? If yes, please describe services received and reason for services: What does your child s teacher(s) say about him/her? FAMILY AND DEVELOPMENTAL HISTORY CHILD S NAME: Include everyone who lives with the child: Name of Person Relation to Child Age of Person Quality of Relationship With Child (Good, Fair or Poor) 2012 Advance Potential Psychological Services Child and Youth Background Info Page 3 of 5

Is there a family history of mental health problems? If yes, who? Mother Father Stepmother Stepfather Siblings Other Relatives Hyperactivity Sexual Abuse Depression Manic Depression Suicide Anxiety Panic Attacks Obsessive-Compulsive Anger/Abusive Schizophrenia Eating Disorder Alcohol Abuse Drug Abuse Parents legally married Living together Parents divorced Permanently separated Parents temporarily separated Father remarried: Number of times Mother remarried: Number of times Please check if your child has experienced any of the following types of trauma or loss: Emotional Abuse Neglect Lived (lives) in a Foster Home Sexual Abuse Violence in the Home Multiple Family Moves Physical Abuse Crime Victim Homelessness Parent Substance Abuse Parent Illness Loss of a Loved One Teen Pregnancy Placed Child for Adoption Financial Problems Were there any medical problems during the pregnancy or birth of your child? If yes, please describe: Did the biological mother use any tobacco, medication, street drugs, or alcohol while pregnant with this child? If yes, please describe substances used, quantity, and frequency: Substance Frequency Amount Tobacco Caffeine Alcohol Cocaine/ Crack Ecstasy Heroin Inhalants Methamphetamines Pain Killers PCP/ LSD Steroids Tranquilizers Marijuana 2012 Advance Potential Psychological Services Child and Youth Background Info Page 4 of 5

Did your child have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)? If yes, please describe: INTERPERSONAL/SOCIAL/CULTURAL INFORMATION Please describe your social support network (check all that apply): Family Neighbors Friends Students Co-workers Support/Self-Help Group Community Group Religious/Spiritual Center (which one?): To which cultural or ethnic group does your child belong? If your child is experiencing any difficulties due to cultural or ethnic issues, please describe: LEGAL INFORMATION If the parents are separated or divorced, what is the current child custody/visitation arrangement? Is your child currently the subject of a custody case? Has your child ever been a ward of the court with DCFS guardianship? Does your child have any legal offenses on record or pending in the courts? Yes No 2012 Advance Potential Psychological Services Child and Youth Background Info Page 5 of 5

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