All fields are required. Write N/A for "not-applicable".

    Who is your clinician?
    Patient Full Legal Name:

    Name of Person Filling Out Form:

    Patient Lives With: Both ParentsMotherFatherOther:

    Brothers: (names, ages, step, half)

    Sisters: (names, ages, step, half)

    Patient's School:
    Grade:
    Teacher:

    What issues are you struggling with at home?

    What issues are you struggling with at school?

    What issues are you struggling with anywhere else?

    What has been tried so far (home, school, etc.)?

    What do you hope to get out of therapy?

    Current exercise: (sports, recreation)

    Previous exercise activities:

    Describe Current Medical Concerns:

    Name of Pediatrician:

    Describe Previous Medical Concerns, Illnesses, Hospitalizations:

    List all Current Medications and Supplements (over-the-counter & prescription):

    Please list all mental health professionals, reason for treatment, and dates of treatment:

    Prenatal and Birth Experience: (labor experience, fetal distress, etc.)

    Describe Developmental Progress: (crawling, walking, talking, etc.)

    Describe Current Family Stressors: (conflict, siblings, parent working away, etc.)

    Most significant head trauma: (accident, sports, fall, etc.)

    Describe any family history of mental illness (depression, anxiety, bipolar, etc.) and if they have been helped by medication:

    Describe any family history of substance abuse or alcoholism:

    Does your child have caffeine? (Type, amount, frequency)
    Do you suspect your child uses any alcohol or recreational drugs? (Type, amount, frequency)
    Describe any struggles with sugar or carb consumption?
    How much screen time per day average?
    Describe any struggles with screens or technology?
    Do you suspect exposure to pornography?
    Any other possible addictions or compulsions?

    Typical times for going to sleep and waking up:

    Sleep: Check all that apply:
    Difficulty Falling AsleepDifficulty Getting out of BedFrequent Nighttime WakingTypically Feel Well-RestedTypically Feel TiredFrequent NightmaresExcessive Daytime NappingBedwetting

    Check all that apply:
    Low self-esteem.Easily angered.Socially nervous.Poor social skills.Frequent conflict with peers.Frequent oppositional behavior.Difficulty finishing tasks.Easily distractedFrequent worry.Verbalizes desire for self-harm.Self-harming actions.Verbally abuses others.Physically abuses others.

    What else would be helpful for me to know about your child?