Information Form
Person Completing Form and Relationship to the Client:
*
Parent/Guardians Phone:
*
Child's Address:
*
Insurance/Number:
*
Previous Placements:
Agencies Involved:
Parent #1 Place of Employment:
*
Parent #2 Place of Employment:
Child's Name:
*
Birthday
*
Age:
*
Description of problem behaviors
*
Married
Divorced
Separated
Never Married
Name/Age/Gender/Relationship of other individuals living in the home:
*
Medical History
Name of Primary Care Physician:
*
Date of last visit:
*
/
Month
/
Day
Year
Date
Primary Care Physician Clinic Name/Address/Phone/Fax Number:
*
Immunizations Current:
*
Yes
No
Allergies
*
YES
NO
If yes, please explain
On any Medication
*
YES
NO
Medications Prescribed, Dr. and dosage
Does your child have any health problems that interfere with normal functioning?
*
Yes
No
If yes, please explain:
Has your child had any surgeries or hospitalizations?
*
Yes
No
If yes, please explain:
Has your child ever been seen by a therapist or counselor?
*
Yes
No
If yes, please provide name and treatment Information:
Development
Complications of pregnancy or delivery:
*
Developmental Milestones:
*
Walked:
*
Sat alone:
*
Crawled:
*
Talked:
*
School Information
Current School:
*
Grade:
*
Teacher Name:
*
Has the school ever conducted any testing on your child?
*
Yes
No
If yes, please explain:
Is there an IEP in place?
*
Yes
No
Family Information
Details on any mental health problems in the family:
*
Details of any Family Medical History, Diabetes, cancer, etc.
*
Does any one over the age of 18 use Nicotine (smoke) in the Home
*
YES
NO
Legal Information
Any legal problems or contact with the law?
*
Yes
No
If Yes, please explain:
Does your child have a history of victimization?
*
Yes
No
Victimization:
*
Physical Abuse
Sexual Abuse
Emotional Abuse
Environmental Neglect
NA
If yes, please explain:
*
Other:
Who do you identify as a support system?
*
Are there any cultural needs you would like us to be aware of?
*
Is there a religion that your family identifies that you would like us to be aware of?
*
What are your discharge goals for your child?
*
What are your child's motivators?
*
Preview PDF
Submit
Should be Empty: