06-07 Child Personal History (Child Admit Packet)

To be completed by parent or guardian. The information you provide to us will be very helpful in treating your child. Please fill out completely. If you have any difficulty, complete as much as possible. Thank you!

Your name *

First Name Last Name

Email *

example@example.com

Child's name *

First Name Last Name Age

Reason for seeking help?

Please review the following list and CHECK the ones that you feel fit your child:

1. Speech difficulties 2. Nervous habits/behavior 3. Frequent headaches 4. Frequent stomach-aches 5. Difficulty sleeping 6. Lacks guilt/remorse 7. Difficulty making friends 8. Difficulty keeping friends 9. Little interest in friends 10. Little interest in activities 11. Disrespectful/argumentative 12. Doesn’t complete schoolwork 13. Acts before thinking 14. Short attention-span 15. Unable to sit still 16. Overactive 17. Underactive 18. Sucks thumb 19. Bangs head 20. Grinds teeth 21. Nightmares 22. Seems angry 23. Hurts animals 24. Sets fires 25. Steals 26. Lies a lot 27. Too serious 28. Fights a lot 29. Clowns a lot 30. Acts spoiled 31. Temper tantrums 32. In own world 33. Afraid/fearful 34. Accident-prone 35. Seems insecure 36. Sad/depressed 37. Worries a lot 38. Cries frequently 39. Mentally slow 40. Interested in sex 41. Looks “high” often 42. Separation problems 43. Imaginary friends 44. Ignores rules 45. Defies authority

Ethnicity (check which one applies):

Hispanic or Latin Hawaiian or Latin Not Hispanic or Latin

Race (check which one applies):

Asian Native Hawaiian Other Pacific Island Black or African American White Hispanic Other Pacific Islander

Does your child have any medical problems? If so, please list

Any surgeries?

Please list any allergies:

Please list all medications the child is currently taking:

Medication

Dosage

Directions

Reason for taking

1

2

3

4

5

6

7

8

9

10

11