Child Supplemental Information

Child Supplemental Information
Child's Name
Date of birth

Month Day Year
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 time Low self worth/self-esteem Apathy/Doesn't seem to care Frequent negative thinking Loss of interest/not enjoying things Decreased energy/fatigue Concentration difficulties Not sleeping/sleeping too much Thoughts of suicide/self-harm Feeling helpless/hopeless Crying spells/cries easily Moodiness/Irritability Anger/angry outbursts Fear of rejection Decreased motivation Racing thoughts Anxiety/Excessive worry Very shy Panic attacks Flashbacks/Nightmares Avoid going places/being with others Checking things repeatedly Obsessive thoughts/Perfectionistic Fear of failure/disapproval
Please check any concerns you have about your child, (section 2):

Need to please or be liked Sensitive to criticism Lacks confidence in abilities Dependent/Needs reassurance Difficulty making decisions Difficulty remembering/losing items Easily distracted Daydreams Needs lots of reminders Doesn't finish things Impulsive/Acts without thinking Demands attention Inattentiveness Hyperactivity Increased risk taking Overly talkative Little need for sleep/Excessive energy On the go all the time Body image difficulties Bites nails/pulls hair Lots of aches/pains Changes in appetite Issues related to sex/sexuality Pornography use
Please check any concerns you have about your child (section3):

Alcohol or drug use Not trusting others Hearing voices others don't hear Seeing things others don't see Temper tantrums Frequently lies Frequently swears Talks back to adults Is confrontational to adults Doesn't follow instructions Can't be trusted Picks on other children Victim of bullies Tries to boss others around Has few or no friends Is seen as weird/different by peers Isolates from others Poor loser Hates going to school/skips school Afraid of going to school Difficulty following school rules Has conflicts with teachers Performs below ability Problems 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?

Yes No
If yes, what type?

Physical Sexual Emotional Other
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?

Yes No
If yes, at what age?
Circumstances of adoption:
Are parents divorced or separated?

Yes No
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?

Yes No
If yes, please explain:
Early Development
Any complications with pregnancy or birth (mother have a significant illness/alcohol use/smoke cigarettes, etc)?

Yes No
If yes, please explain:
Any problems with development or health (failure to thrive/ low oxygen/delay meeting milestones)?

Yes No
If yes, please explain:
Where does your child attend school?
Current grade level
Typical grades?
Any school behavior problems?
Should be Empty: