Child Supplemental Information

Child Supplemental Information
Child's Name
Date of birth

MonthDayYear
Date
Form completed by
Relationship to child
Referred by
Primary reason for scheduling appointment:
Please check any concerns you have about your child (section 1):

Sad or unhappy most of the timeLow self worth/self-esteemApathy/Doesn't seem to careFrequent negative thinkingLoss of interest/not enjoying thingsDecreased energy/fatigueConcentration difficultiesNot sleeping/sleeping too muchThoughts of suicide/self-harmFeeling helpless/hopelessCrying spells/cries easilyMoodiness/IrritabilityAnger/angry outburstsFear of rejectionDecreased motivationRacing thoughtsAnxiety/Excessive worryVery shyPanic attacksFlashbacks/NightmaresAvoid going places/being with othersChecking things repeatedlyObsessive thoughts/PerfectionisticFear of failure/disapproval
Please check any concerns you have about your child, (section 2):

Need to please or be likedSensitive to criticismLacks confidence in abilitiesDependent/Needs reassuranceDifficulty making decisionsDifficulty remembering/losing itemsEasily distractedDaydreamsNeeds lots of remindersDoesn't finish thingsImpulsive/Acts without thinkingDemands attentionInattentivenessHyperactivityIncreased risk takingOverly talkativeLittle need for sleep/Excessive energyOn the go all the timeBody image difficultiesBites nails/pulls hairLots of aches/painsChanges in appetiteIssues related to sex/sexualityPornography use
Please check any concerns you have about your child (section3):

Alcohol or drug useNot trusting othersHearing voices others don't hearSeeing things others don't seeTemper tantrumsFrequently liesFrequently swearsTalks back to adultsIs confrontational to adultsDoesn't follow instructionsCan't be trustedPicks on other childrenVictim of bulliesTries to boss others aroundHas few or no friendsIs seen as weird/different by peersIsolates from othersPoor loserHates going to school/skips schoolAfraid of going to schoolDifficulty following school rulesHas conflicts with teachersPerforms below abilityProblems with homework
Are there other concerns (not listed above) you want to discuss?
How have these concerns impacted your child's daily life?
Has your child been a victim of trauma, abuse, or neglect?

YesNo
If yes, what type?

PhysicalSexualEmotionalOther
If yes, please explain
Past Mental Health Treatment/Psychological Assessment:

Has your child ever previously received inpatient, outpatient, IOP/partial, or psychological assessment services?
Instance 1. When?
Instance 1. Where?
Instance 1. Outcome?
Instance 2. When?
Instance 2. Where?
Instance 2. Outcome?
Family & Supportive Relationships:
Is the child adopted?

YesNo
If yes, at what age?
Circumstances of adoption:
Are parents divorced or separated?

YesNo
If yes, how long?
Current custody/visitation arrangements?
Please tell about the household/family with whom your child spends the majority of his or her time/currently lives with. List primary household first and then other living situations/supportive relationships.
Name #1 Age Relationship Relationship Quality Living with Child?
Name #2 blanks Age blank Relationship Relationship Quality Living with Child?
Name #3 blanks Age blank Relationship Relationship Quality Living with Child?
Name #4 blanks Age blank Relationship Relationship Quality Living with Child?
Name #5 blanks Age blank Relationship Relationship Quality Living with Child?
Name #6 blanks Age blank Relationship Relationship Quality Living with Child?
Name #7 blanks Age blank Relationship Relationship Quality Living with Child?
Name #8 blanks Age blank Relationship Relationship Quality Living with Child?
Name #9 blanks Age blank Relationship Relationship Quality Living with Child?
Do you have any concerns about your child's relationship with a family member?

YesNo
If yes, please explain:
Early Development
Any complications with pregnancy or birth (mother have a significant illness/alcohol use/smoke cigarettes, etc)?

YesNo
If yes, please explain:
Any problems with development or health (failure to thrive/ low oxygen/delay meeting milestones)?

YesNo
If yes, please explain:
Where does your child attend school?
Current grade level
Typical grades?
Any school behavior problems?
Should be Empty: