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:
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Date of last visit:
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/
Month
/
Day
Year
Date
Primary Care Physician Clinic Name/Address/Phone/Fax Number:
*
Immunizations Current:
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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?
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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:
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Walked:
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Sat alone:
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Crawled:
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Talked:
*
School Information
Current School:
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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:
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Other:
Who do you identify as a support system?
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Are there any cultural needs you would like us to be aware of?
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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?
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What are your child's motivators?
*
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