Child Information Form CHILD INFORMATIONFirst Name *Last Name *Date of 1st Appointment Therapist Gender *Date of Birth *Age * MEDICAL HISTORYName of Primary Care Physician: Physician’s Phone Physician’s Address Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)CongoCosta RicaCote d\'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalestinian TerritoryPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaWestern SamoaYemenZambiaZimbabweCountryMany managed care companies require that we have interaction with the client’s physician to coordinate care. Do you give us consent to discuss your care with the above named doctor? YesNoDate of last medical evaluation mm/dd/yyDate of next appointment mm/dd/yyCurrent medications being takenMedication 1: Dosage/Frequency Start Date Purpose Medication 2: Dosage/Frequency Start Date Purpose Medication 3: Dosage/Frequency Start Date Purpose Medication 4: Dosage/Frequency Start Date Purpose Prescribed by HospitalizationHas your child ever been hospitalized for medical or psychiatric reasons? YesNoHospital Date Reason Hospital Date Reason Hospital Date Reason Describe any important medical history, chronic ailments, or other health problems your child experiences Describe any other health problems or important medical history about your child’s immediate family members and close relatives, including chronic ailments Does your child have any close relatives (father, mother, brother, sister, grandparent) who have experienced depression, anxiety, or other emotional difficulties? Please list SCHOOL HISTORYDoes your child experience any developmental, academic or behavior problems while in school or daycare, with peers or teachers? YesNoIf yes, please explain What was the last year of school your child completed? What school is he/she attending? Is your child home-schooled? YesNoPlease check all information which applies to your child’s biological parentsMother livingdeceasedmarrieddivorcedremarriedFather livingdeceasedmarrieddivorcedremarriedIf Mother remarried, how many times? If Father remarried, how many times? With whom does your child live? What custody and/or visitation orders are in place? * Please copy orders to be placed in client’s file. Does your child consider anyone else to be a “parent” in his/her life? YesNoIf yes, whom? Describe your relationship with your childCurrently In the past Describe your child’s relationship with his/her other parentCurrently In the past List first names and ages of your child’s brothers & sisters1) Name Age Relationship (biological, step, half, etc.) Lives with? 2) Name Age Relationship (biological, step, half, etc.) Lives with? 3) Name Age Relationship (biological, step, half, etc.) Lives with? 4) Name Age Relationship (biological, step, half, etc.) Lives with? Describe any problems which occurred in your child’s family relating to:Alcohol/drug abuse Sexual/physical/emotional abuse Others living in the home with your child1) Name Age Relationship Grade/Occupation 2) Name Age Relationship Grade/Occupation 3) Name Age Relationship Grade/Occupation 4) Name Age Relationship Grade/Occupation MENTAL STATUSPlease check any of the following that describe how you believe your child has been feeling lately sadanxiousdepressedfrightenedguiltyangryashamedaggressiveresentfulworthlesstearfulirritableconfusedextreme ups/downsjealoushopelesshelplessDescribe any behaviors your child has demonstrated that cause concern Has your child had any change in sleeping habits? YesNoDescribe: Has your child had any change in eating habits? YesNoDescribe: Has your child ever considered suicide in connection with his/her current problem? YesNoIf so, please give a brief description with dates: Has your child ever considered suicide in the past? YesNoHas your child attempted suicide recently or in the past? YesNoIf so, please give a brief description with dates: Has your child tried to hurt others or animals recently or in the past? YesNoIf yes, please explain: LEVEL OF FUNCTIONINGPlease describe what activities your child participates in Who is in your child’s support network? Please describe your child’s level of physical activity How much time does your child play on the computer, watch TV, or play video games OTHER INFOIs there any other information regarding your child that you would like to share with your child’s Therapist that is not covered on this form? You may also use this space to complete earlier responses. Please list your therapy goals for your child THANK YOU! VerificationPlease enter any two digits *Example: 12This box is for spam protection - <strong>please leave it blank</strong>:
