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Personal History - Child/Adolescent

Jewish Family and Career Services of Atlanta
4549 Chamblee Dunwoody Road
Phone 770.677.9389
Fax 770.677.9400
 Client Information
  First Name:  * Last Name:  *  
           
  Date of Birth:  * Birth Sex: 
* 
         
  Address: City:  
  State: Zip Code :  
  Phone No:  
Current School:
Current/Highest level of education:
Identifying Information
Parent/Caregiver
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
This Parent/Caregiver is:
Natural Parent   Adoptive Parent   Step Parent  
Parent/Caregiver DOB:
Education:
Occupation:
Parent/Caregiver
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
This Parent/Caregiver is:
Natural Parent   Adoptive Parent   Step Parent  
Parent/Caregiver DOB:
Education:
Occupation:
Parent/Caregiver
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
This Parent/Caregiver is:
Natural Parent   Adoptive Parent   Step Parent  
Parent/Caregiver DOB:
Education:
Occupation:
Parent/Caregiver
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Email:
This Parent/Caregiver is:
Natural Parent   Adoptive Parent   Step Parent  
Parent/Caregiver DOB:
Education:
Occupation:
Number of members in Household
Household Member Information
  Name Gender Age Relationship to client Quality of relationship
Household Member 1:
Household Member 2:
Household Member 3:
Household Member 4:
Household Member 5:
Household Member 6:
Household Member 7:
Household Member 8:
Do you have any children that live outside of the home?
If yes, how many and whom do they live with?
Total Household Income
Why are you seeking professional help at this time?
Difficulty with:
  NOW Past
Anxiety
Depression
Mood Changes
Anger/Temper
Panic
Fears
Irritability
Concentration
Headaches
Loss of Memory
Excessive
Wetting the Bed
Trusting Other
Communicating with Others
Separation Anxiety
Alcohol/Drugs
Drinks/Caffeine
Frequent Vomiting
Eating Problems
Severe Weight Gain
Severe Weight Loss
Head Injury
Tantrums
Parents Divorced
Seizures
Cries Easily
Problems with Friends(s)
Difficulty Learning
Fear of Strangers
Issues re: Divorce
Sexually Acting Out
History of Child Abuse
History of Sexual Abuse
Domestic Violence
Fighting with Siblings
Thought of Hurting Someone Else
Hurting Self
Thoughts of Suicide
Sleeping Too Much
Sleeping Too Little
Getting to Sleep
Waking too Early
Nightmares
Sleeping Alone
Nausea
Stomach Aches
Fainting
Dizziness
Shortness of Breath
Diarrhea
Chest Pain
Sweating
Muscle Tension
Lump in the Throat
Fidgets Frequently
Verbal Expression
Waiting His/hers Turn
Often Makes Careless Mistakes
Bruises Easily
Allergies
Impulsive
Completing Tasks
Paying Attention
Easily Distracted by Noises
Hyperactivity
Sensory Processing
Tics
DEVELOPMENTAL HISTORY
Is the child a product of a planned pregnancy?
Did mother have any illness(s) or complications before delivery?
If yes, please explain:
Did mother use/abuse alcohol or drugs during pregnancy?
Length of pregnancy:
Was the pregnancy full term?
Were there any complications at birth?
If yes, please explain:
As far as you know, did your child meet developmental milestones at an appropriate age?
Language:
Motor:
Toileting:
Age of Delayed Milestones for Langauge
  Age of Onset
First Words
Two words together
Pronouns
Colors and Numbers
Age of Delayed Milestones for Motor Skills
  Age of Onset
Able to Roll Over
Able to Sit
Able to Crawl
Able to Walk
Able to Climb Stairs
Able to Ride Tricycle
MEDICAL HISTORY
Please explain any significant medical problems, symptoms, or illnesses your child has had:
Does the child have any allergies that you are aware of?
Date of most recent hearing and vision screenings. Any concerns noted?
Previous medical hospitalizations (approximate dates and reasons):
Previous psychiatric hospitalizations (approximate dates and reasons):
Primary Care Physician
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone:  
(Business)
   (Cell)
Fax:
Email:
Neurologist
Name:
Address:
Address Line 2:
City: State: Zip Code:
Phone: (Home)
  
(Business)
   (Cell)
Fax:
Email:
Current Medications
  Name of Medication Dosage Purpose Name of Prescribing Doctor
1.
2.
3.
4.
5.
6.
7.
8.
Other Medications not listed above:
Has your child ever talked with a psychiatrist, psychologist, or other mental health professional? (If yes, please list approximate dates and reasons):
Has your child ever participated in occupational, physical or speech and language therapies or tutoring? (If yes, please list approximate dates and reasons):
FAMILY
Relationship Status of Parents"
If divorced, how old was the child when the parents separated or divorced and how do you think this impacted him or her?
If applicable, please describe the Parenting Plan, including custody and schedule.
How would you describe your child’s relationship with his/her parents? Please list each separately.
Are there any other primary caregivers who have had a significant relationship with your child?
If yes, please describe how these people may have impacted your child’s life:
Family History (check all that apply and indicate if maternal or paternal)
  Yes/No Maternal Paternal
Drug/Alcohol Problems
Legal Trouble
Domestic Violence
Suicide
Physical Abuse
Sexual Abuse
Hyperactivity/Inattention
Learning Disabilities
Depression
Anxiety
Psychiatric Hospitalization
“Nervous Breakdown”
Epilepsy
Tic Disorder
Migraines
Other Genetic Disorder
Please explain:
SOCIAL SUPPORT, SELF-CARE, & EDUCATION:
Child’s current level of satisfaction with friends and social support:
How would you describe your child’s relationships with his/her peers?
Please briefly describe any history of abuse, neglect and/or trauma:
What are your child’s diet, weight, and exercise/activity patterns?
What are your child’s hobbies and talents?
Primary methods of discipline:
Please briefly describe your child’s school performance and experience:
Education History
  Name of School Grade (Pre-K - 12) Learning/Behavioral Concerns
1.
2.
3.
4.
5.
Has your child had a psychological/psychoeducational evaluation in the past?
Have there been any diagnosed learning disabilities in the child in the past?
If yes, please describe:
Emotions (Briefly describe the child’s way of expressing the following emotions or behaviors)
Anger:
Happiness:
Sadness:
Anxiety:
Strengths (List the child’s three greatest strengths)
1.
2.
3.
Weaknesses (List child’s three greatest weaknesses or areas needing improvement)
1.
2.
3.
Additional Information
Any additional information you would like to include:
Were you referred by another clinician?
If yes, would you like for us to communicate with one another?
Yes, name of clinician:   No  
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