CHILD PERSONAL HISTORY FORM

CHILD PERSONAL HISTORY FORM
Please complete and submit. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your child.
Child's legal name*
Child's name they go by:

First NameLast Name
Child's pronouns:

She/herHe/himThey/themOther
Date*

MonthDayYear
Date
Gender identity:*
Name of person filling out the form*
Client DOB*

MonthDayYear
Date
Preferred contact phone #*
Relationship to child*
Social Security*
Alternative phone #
Address*
Email*
example@example.com
Emergency contact name & phone #*
Parent 1's name:*
Parent 2's name:*
Names of siblings*
Seeking the following services:*

Relationship Development Intervention (RDI)Individual TherapyParent TrainingBehavioral TherapyGroup TherapyFamily TherapyEducational ConsultationOther
Primary reason(s) for seeking services:*

Autism SpectrumAnger ManagementCopingFear/PhopiasCompulsive BehaviorsSocial IssuesParenting IssuesDepressionSexual ConcernsAlcohol/DrugsDevelopmental DelaysAnxietyEating DisorderSleeping ProblemsHyperactivity
Other mental health concerns (specify):*
Please select*

I'd rather not sayAmerican IndianAsianBlackHispanicPacific IslanderWhiteTwo or more racesOther
Language(s) spoken at home:
Religious preference, if applicable
Please answer the following questions to the best of your ability:
1. Goals: What are your goals for coming here? Please be as specific as possible.
2. Opinions a: Is there any difference of opinion among different family members over whether problems exist, or what needs to be done? If so, please give us each person’s viewpoint of the problems and solutions.
3. Opinions b: How about others who know your child (i.e., teachers)? Have they noted any problems or differences? What is their view about what needs to be done to address these issues? Is there any difference of opinion between you and the school? If so, please give us their viewpoints as well as yours.
4. Living arrangements: With whom does the child live at this time? *
Child expectations: Does the child know why they are coming? If so, what do they know and expect?*
6.Marriage: Please tell us about parents’ marital status. Is this the first marriage for both? If there were prior marriages, are there any children from them? Are parents divorced? Remarried? Separated? If divorced, tell us your opinion of the impact of the divorce on the child. Is there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling?*
7. Parent 1:*

Natural ParentStep-ParentAdoptive ParentFoster HomeOther
Please tell us about your occupation.
Is parent 1 currently working?*
Part time/full time*
Name of parent 1's employer*
Work phone*
Parent 1's education:*
Is there anything notable, unusual or stressful about the child’s relationship with the parent 1?*

YesNo
If Yes, please explain:*
How is the child disciplined by parent 1?*
For what reasons is the child disciplined by parent 1?*
8. Parent 2:*

Natural ParentStep-ParentAdoptive ParentFoster HomeOther
Is parent 2 currently working?*
Part time/full time?*
Name of parent 2's employers:*
Work phone:*
Parent 2's education:*
Is there anything notable, unusual or stressful about the child’s relationship with the parent 2?*

YesNo
If Yes, please explain*
How is the child disciplined by parent 2?*
For what reasons is the child disciplined by parent 2?*
9.Adoption: If your child was adopted, at what age was the adoption? What information do you have about the history of the biological parents and the child’s his tory before the adoption?*
10.Brothers and sisters: Tell us any important information about siblings that would help us. Please include quality of the relationship with client.*
11. Caregivers: Please tell us about the adults involved with this child on a regular basis.*
12. Family Health
Have any of the following diseases occurred among the child’s blood relatives? (parents, siblings, aunts, uncles or grandparents) Check those which apply:*

No health issuesAllergiesAnemiaPerceptual Motor DisorderMuscular DystrophyBlindnessCancerCerebral PalsyCleft LipsCleft PalateDiabetesGlandular ProblemsHigh Blood PressureKidney DiseasesMental IllnessMigrainesMultiple SclerosisDeafnessNervousnessAsthmaSeizuresSpina BifidaSuicideOther
Comments re: family health:*
13.Stress: Please tell us about any recent stresses and crises that have occurred in the family in the last few years. For any stress you list, tell us how you think it may have affected your child. (Include a parent who must work unusually long hours in the list of stresses. Also, include any anticipated future stresses*
14. Pregnancy: Please tell us about the pregnancy and delivery of this child. Were there any stresses or problems?*
15. Early: Please tell us anything significant about this child’s first months of life. What, if anything did you notice was significant in the first year? What about his or her development was different from what you expected?*
16. First 18 months: Please share anything you feel is especially notable about the child’s early development during the first 18 months. What about his or her development was different from what you expected?*
17. Medical History: Please indicate anything notable about the child’s medical status, including neurological problems and allergies.
No health issuesAbortionAsthmaBlackoutsBronchitisHivesCerebral PalsyChicken PoxCongenital ProblemsCroupDiabetesSexually Transmitted DiseaseDizzinessEar AchesEar InfectionsEczemaEncephalitisHay FeverHeart TroubleHepatitisHearingRheumatic FeverInfluenzaLead PoisoningMeaslesMeningitisMiscarriageMultiple SclerosisMumpsMuscular DystrophyNose BleedsOther Skin RashesParalysisPneumoniaPolioPregnancySpeechSensory/MotorScarlet FeverSeizuresSevere ColdsHeadachesThyroid DisordersVision ProblemsWearing GlassesWhooping CoughOther
List any current health concerns*
List any recent health or physical changes: *

Current prescribed medications

	Current Prescribed Medications	Dose	Dates	Side Effects	Purpose
Medication 1
Medication 2
Medication 3
Medication 4

Current over the counter medication

	Current over the counter medications	Dose	Dates	Side Effects	Purpose
Medication 1
Medication 2
Medication 3
Medication 4

Pediatrician/Prescriber’s Information:
Name of Pediatrician/Prescriber:
Office Name of Pediatrician/Prescriber:
Pediatrician/Prescriber’s address:
Phone # of Pediatrician/Prescriber:
18. Education:
Current school:*
School phone number:*
Type of school*

PublicPrivateHome schooledOther
Grade:*
Teacher:*
School counselor:*
In special education?*

YesNo
If Yes, describe:*
In gifted program?*

YesNo
If Yes, describe*
Has child ever been held back in school?*

YesNo
If Yes, describe*
Which subjects does the child enjoy in school?*
Which subjects does the child dislike in school?*
What grades does the child usually receive in school?*
Has there been any recent changes in the child's grades?*

YesNo
If Yes, describe*
Has the child been tested psychologically?*

YesNo
If Yes, describe*
Check the descriptions which specifically relate to your child.
Feelings about school/work*

AnxiousFearfulEagerRebelliousPassiveNo ExpressionEnthusiasticBored
Other (please describe)*
Approach to school work:*

OrganizedIndustriousResponsibleInterestedSelf-DirectedNo InitiativeRefusesDoes Only What is ExpectedSloppyDisorganizedCooperativeDoesn't Complete Assignments
Other (describe)
Performance in school (parent’s opinion):*

SatisfactoryUnderachieverOverachieverOther
Child’s peer relationships:*

SpontaneousFollowerLeaderDifficulty Making FriendsMakes Friends EasilyLong-Time FriendsShares EasilyOther
Who handles responsibility for your child in the following areas?
School*

Parent 1Parent 2SharedOther
Health*

Parent 1Parent 2SharedOther
Problem behavior*

Parent 1Parent 2SharedOther
If the child is involved in a vocational program or works a job, please fill in the following:
What is the child's attitude towards work?*

PoorAverageGoodExcellent
Current employer:*
Position:*
Hours per week:*
How have the child’s grades in school been affected since working?*

LowerSameHigher
Higher how many previous jobs or placements has the child had?*
Usual length of employment:*
Usual reason for leaving*
19.Counseling/prior treatment history: Please share with us any prior about any prior counseling the child has received. What worked? What did not work?*
20. Behavioral/emotional
Please check any of the following that are typical for your child:*

AffectionateSadAggressiveRageSelfishGamblingSets FiresFrustrated Easily/Poor Frustration ToleranceDifficulty attaching to CaregiversLimited Emotional ExpressionCan't Stop Him/Herself from Taking Actions when Specifically Warned of ConsequencesAlcohol ProblemsAnxietyAngerSexual Addiction/Sexual Acting OutDifficulty Shifting AttentionDoesn't Understand or Show Anxiety for Hazards such as Fire, Cliffs, Etc.HopelessnessShort Attention SpanSick OftenBlinking/JerkingImpulsiveBullies/ThreatensSleeping ProblemsLazyLearning ProblemsClumsyDifficulty Understanding ConsequencesApproaching StrangersSeparation AnxietyHallucinationsHead-BangingOvoids AdultsOver FocusedHurts AnimalsBedwettingBizarre BehaviorsImaginary FriendsShy/TimidIrritableCareless/RecklessSlow-movingSoilingLies FrequentlyStealsCyber-AddictionSuicidal ThreatsMessySpeech ProblemsLonerLow Self-EsteemDefiantSuicidal AttemptsMoodyDestructiveTeeth GrindingObedientDizzinessToilet IssuesDrug DependenceUnsafe BehaviorsPicky EatingOver ActiveEnthusiasticWeight LossPanic AttacksExpects FailureWorries ExcessivelyPoor appetiteFearfulFrequent InjuriesDepressionTalks BackNightmaresDifficulty SpeakingThumb SuckingOften SickTics or TwitchingOppositionalEating DisorderFood AversionsUnusual ThinkingOverweightExcessive MasturbationWithdrawnPhobiasFatiguePsychiatric ProblemsQuarrels with OthersOther
21.Leisure/strengths:
Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc What are the family’s favorite activities? What does the child/adolescent do with unstructured time? What would you consider your child’s strengths to be?*
Any additional information that you believe would assist us in understanding your child/adolescent?*
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