Information Form
Person Completing Form and Relationship to the Client:
*
Parent/Guardians Phone:
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Child's Name:
*
Child's Address:
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Insurance/Number:
*
Previous Placements:
Agencies Involved:
Parent #1 Place of Employment:
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Parent #2 Place of Employment:
Birthday
*
Age:
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Married
Divorced
Separated
Never Married
Other Individuals Living in the Home:
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Name
Age
Gender
Relationship
Name/Age/Gender/Relationship to other individuals 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:
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Immunizations Current:
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Yes
No
Medications Prescribed:
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?
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Yes
No
If yes, please explain:
Has your child ever been seen by a therapist or counselor?
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Yes
No
If yes, please provide name and treatment Information:
Development
Complications of pregnancy or delivery:
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Developmental Milestones:
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Walked:
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Sat alone:
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Crawled:
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Talked:
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School Information
Current School:
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Grade:
Teacher Name:
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Has the school ever conducted any testing on your child?
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Yes
No
If yes, please explain:
Is there an IEP in place?
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Yes
No
Family Information
Details on any mental health problems in the family:
*
Legal Information
Any legal problems or contact with the law?
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Yes
No
If Yes, please explain:
Does your child have a history of victimization?
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Yes
No
Victimization:
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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?
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What are your discharge goals for your child?
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What are your child's motivators?
*
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