Child & Family Information Form
Behavioral Diagnostics & Treatment - Behavioral Neuropsychology, LLC
Date Form Completed
/
Month
/
Day
Year
Date
Person Completing Form
First Name
Last Name
Relationship to Patient
Please Select
Mother
Father
Stepmother
Stepfather
Guardian
Self
Other
Person Completing this form preferred E-Mail Address
Preferred Phone of form completeer
Ok to include you in our follow-up surveys about your satisfaction?
Please Select
YES
NO
Child, Teen, or Patient's Name
First Name
Last Name
Child, Teen, or Patient Initials
Child, Teen, or Patient's DOB
/
Month
/
Day
Year
Date
Child, Teen, Patient's Gender
Please Select
Female
Male
Other
Do no want to say
Child, Teen, Patient's School
Child, Teen, or Patient's Grade
Please Select
KG
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12
College Freshman
College Sophomore
College Junior
College Senior
College Unspecified
Community College
Graduate School
Medical School
Other
Teacher's Name
Please Select
KG
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12
College Freshman
College Sophomore
College Junior
College Senior
College Unspecified
Community College
Graduate School
Medical School
Other
School Address
Are parents divorced?
Yes
No
Is custody joint?
Yes
No
If custody IS NOT joint please list name of non-custodial parent
First Name
Last Name
Non-custodial parent's email address or phone number
Child or Teen is
Right Handed
Left-Handed
Mixed-Handed
Ambidextrous
At what age did your child or teen
Age 1-2
Age 3-4
Age 4-5
Age 5 +
Is Child or Teen Adopted?
Yes
No
If adopted, at what age?
If adopted, please provide details when, where, prenatal and postnatal care level.
How many times have you moved since child's Birth?
0
1-2
3-4
5-6
>6
Does Child or Teen attend Religious Services?
Yes
No
Religious Affiliation
Who referred you to us? [name of referral source]
First Name
Last Name
Phone # for referral source or practice?
Please enter a valid phone number.
Check all services you're interested i pursuing for your child or teen.
Therapy
Comprehensive Assessment
Limited Assessment =
Homework Coaching
In Home Services
Consultation
Other
Your goals for assessment, therapy, or coaching.
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Page 2 - Child & Family Info Form
Continued
Please tell us about your main concerns about your child or teen at this time?
Please select the CURRENT concerns you have about your child or teen? [Check all that apply]
Not minding
Whining
Defiance
Bickering/Arguing
Lying
Stealing
Aggression
Hitting
Lack of Friends
Friend Choices
Bullying Others
Bullied by Others
Temper tantrums
Rage Episodes
Disorganization
Forgetfulness
Memory Probs
Lose Pers Items
Nightmares
Night Terrors
Excess Scrn Time
Excess Gaming
Excess Soc Med
Headaches
Stomachaches
Overeating
Poor Appetite
Moodiness
Frequent Crying
Low Self-Esteem
Giving up Easily
Oft Discouraged
Overly Active
Lack of Exercise
Perfectionism
Neg Self-Talk
Nightmares
Insomnia
Often Sleeping
Sleeps Little
Drug Use
Alcohol Use
Tobacco Use
Obsessions
Repetitive Behs
Ritual Behaviors
Sexual Behaviors
Enuresis
Encopresis
Eating issues
Self Harm
Suicidal thoughts or actions
Other
If your child loses personal items, please check the things they lose frequently [Check all that apply]
Hats
Coats
Gloves
Books
Book Bags
Glasses
Sports Equipment
Computer
Phone
Other
Please select PAST concerns you have had about your child or teen? [Check all that apply]
Not minding
Whining
Defiance
Bickering/Arguing
Lying
Stealing
Aggression
Hitting
Lack of Friends
Friend Choices
Bullying Others
Bullied by Others
Temper tantrums
Rage Episodes
Disorganization
Forgetfulness
Memory Probs
Lose Pers Items
Nightmares
Night Terrors
Excess Scrn Time
Excess Gaming
Excess Soc Med
Headaches
Stomachaches
Overeating
Poor Appetite
Moodiness
Frequent Crying
Low Self-Esteem
Giving up Easily
Oft Discouraged
Overly Active
Lack of Exercise
Perfectionism
Neg Self-Talk
Nightmares
Insomnia
Often Sleeping
Sleeps Little
Drug Use
Alcohol Use
Tobacco Use
Obsessions
Repetitive Behs
Ritual Behaviors
Sexual Behaviors
Enuresis
Encopresis
Eating issues
Self Harm
Suicidal Thoughts or Actions
Other
Please use this space to further explain any of your CURRENT or PAST concerns
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Family Members & Others living in the home
Name
Age
School Grade
Ed Level
Current Job
Race
Mother
Father
Sibling 1
Sibling 2
Sibling 3
Sibling 4
Others Living
in Home
Others Living
in Home
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Early Developmental History
Did anything unusual occur during your pregnancy, labor, or delivery?
Yes
No
If yes to the previous question, please elaborate.
Did birth mother smoke, drink, or use drugs during pregnancy?
Yes
No
If yes to the previous question, please elaborate.
Did your child require special or extra care, or were they re-admitted to the hospital as a newborn or infant?
Yes
No
If yes to the previous questions, please elaborate.
Birth Weight & Birth Length & APGAR
As an infant was your child...? [all that apply]
Predictable with sleep?
Unpredictable with sleep?
Predictable with eating?
Unpredictable with eating
Predictable in being soothed?
Unpredictable in being soothed?
Other
What did you enjoy most about your child as a newborn and infant?
What was most difficult about your child as a newborn or infant?
What is your Child's hand preference?
Right
Left
Ambidextrous
Unsure
At what age did your child show a hand preference?
12 -24 Months
24-36 Months
36-48 months
> 48 months
Other
Did your child attain all developmental stages within the normal limits or times?
Please Select
Yes
No
See Notes
Age [in Months] your child sat unsupported?
Age in Months Child Was Bladder Trained?
Age in Months Child Was Bowel Trained?
Age in Months Child had a dry Bed
Walked Unsupported at age...?
First Words at age...?
Anything else that occurred from 0-3 years you thought might affect his/her normal growth, development, or school success?
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Health Care History
Previous Illnesses your child has experienced
Celiac Disorder
Headaches
Concussion
Drug Allergies
Drug Reaction
Encephalitis
Growth Problems
Hearing Problems
LD Diagnosis
Meningitis
Migraine HA
Freqnt Earaches
Freqnt Resp Inf
Seizures
Tiring Easily
T1 Diabetes
Type 2 Diabetes
Vision Problems
Stomachaches
Other
Age of diagnosis and or other details or comments about previous illnesses listed above?
Your child's Physician or Pediatrician?
Phone for Child's Physician/Pediatrician?
Your child's Psychiatrist/MH Practitioner?
Email or Phone for Psychiatrist/MH Practitioner?
Does or has your child take medications on a daily or regular basis? If so, please check all
Adderall
Adderall XR
Concerta
Cylert
Cymbalta
Dexedrine
Effexor
Focalin
Intuniv
Prozac
Ritalin
Methylphenidate
Tenex
Vyvanse
Wellbutrin
Other
Dosages and prescribers [physicians or nurse practitioners] for medications listed above.
Behaviors, Habits, Emotion Regulation
Has your child or teen been treated for psychological problems?
No Previous Treatment
Outpatient Treatment
Intensive OP Treatment
Inpatient Treatment
Individual Treatment
Drug & Alc Treatment
Family Therapy
CBT/ACT
DBT
Behavior Therapy
Medications
Exposure Therapy
Residential Treatment
Wilderness Treatment
Other
Details on any checked items above:
Has your child or teen had any of these experiences, issues, or problems?
Physical abuse
Sexual abuse
Run away from home
Arrested or adjudicated
Set a fire
Assaulted someone
Destroyed property
Hurt self
Threatened to hurt self
Threatened others
Used a weapon
Used alcohol /drugs
Used tobacco
Grades dropped lots
Had tutors/Ed Specialists
Sexually active
Cruelty to animals
Rituals, compulsive behaviors
Rigidity in Thinking
Shyness
Social Problems
Other
Details on any checked items above [e.g. who, when, duration, treated or untreated, severity
MOTHER - What percent of the time does your child or teen follow through with your requests?
FATHER - What percent of the time does your child or teen follow through with your requests?
Does your child or teen warrant discipline?
Never
Not very often
Not often
Sometimes
Often
Very Often
Describe situations in which your child or teen warrants discipline?
What types of discipline are effective for your child?
Ignoring
Spanking
Rewards/Incentives
Lecturing
Natural Consequences
Yelling
Time Outs
Work Chores
Nothing seems to work
Other
Any other comments about ANY behaviors or emotion regulation problems.
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School & Learning History
Schools Your Child has attended [Add rows, and please include Pre-KG and pre-schools]
Has Your Child or teen been classified as having? [Check all that Apply]
Reading Disability
Speech Disability
Language Disability
Math Disability
Severe Emotional Disability
Executive Skill Disability
Other Health Impaired
T1 Diabetes
ADHD
Other
Is your child or teen currently on an IEP?
Yes
No
Is your child or teen currently on a 504 plan?
Yes
No
Is your child or teen currently in special classes or a resource room?
Yes
No
In which grades has your child or teen had special ed, IEP, or 504 plans?
Pre-KG
KG
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
What accommodations does your child or teen use at school?
Any additional comments or details about your child or teen's learning problems?
Has your child or teen had individual psychological testing in school?
Yes
No
If yes to psychological testing in school, when and at what school?
Has your child or teen been seen by a school counselor?
Yes
No
If your child or teen has been seen by a counselor, what for?
Has your child or teen skipped a grade?
Yes
No
Has your child or teen repeated a grade?
Yes
No
If your child or teen repeated or skipped a grade, please tell us the details of when and why?
Have your child or teen's grades changed recently?
Please Select
Getting a lot better
Getting slightly better
Have Stayed the Same
Getting slightly worse
Getting a lot worse
What were your child or teen's grades last term?
What is your child or teen's GPA?
Does your child or teen have any behavior problems at school currently?
Yes
No
Has your child or teen had any behavior problems at school in the past?
Yes
No
Details about any current or past behavior problems at school for your child or teen?
Does your child or teen have problems getting along with other children?
Yes
No
Does your child or teen have a best friend or a close group of school friends?
Yes
No
Details about any current or past problems at school getting along with peers?
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Homework & Schoolwork Habits
How long does your child or teen spend on daily homework?
Please Select
None
0 - 30 minutes
30 minutes - 1 hour
1 - 2 hours
2 - 3 hours
3 - 4 hours
4+ hours
How long do you/another parent spend on daily homework with your child or teen?
Please Select
None
0 - 30 minutes
30 minutes - 1 hour
1 - 2 hours
2 - 3 hours
3 - 4 hours
4+ hours
How difficult is it for your child or teen to start homework?
Very easy, a self-starter
Easy
Neutral
Hard
Very hard, most times
As a rule, does your child or teen complete and hand in homework?
Completes & hands in homework often
Often completes, but does not hand in often
Often neither completes nor hands in
Other
Further comments or notes about homework, schoolwork, studying, or academic performance?
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Family & Extended Family Health History
Please check whether any relatives have had any of these problems [Explain in the next text box].
Mother's Family
Father's Family
Learning Problems
Reading Problems
Alcohol Abuse
Drug Abuse
Legal Problems
Inattention Issues
Hyperactivity
Mood Problems
Depression
Bipolar Disorder
Mental Retardation
Obsessions or Compulsions
Perfectionism
Tics/Involuntary Movements
Anger Problems
Anxiety Problems
Social Anxiety
Emotional Regulation
Executive Skills Issues
Psychosis/Schizophrenia
Explain checked items above if necessary.
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Favored Activities, Entertainment, Strengths
What are your child or teen's favorite activities?
Does your child or teen have a best friend?
Yes
No
Does your child or teen play with a regular group of kids at school?
Yes
No
Does your child or teen play with a regular group of kids at home?
Yes
No
Does your child or teen have problems making friends or getting along with kids?
Yes
No
Does your child or teen have trouble getting along with siblings?
Yes
No
Does your child have trouble getting along with teachers or adults?
Yes
No
Comments on friendship and sibling relationships.
What activities do you like to do with your child or teen?
What are your child or teen's strong points or personal strengths?
What does your family like to do together?
How often do you read to your child?
How often does your child read on her/his/their own? What are your child's favorite reading materials?
Hours your child watches TV/ streams on a typical weekday?
Hours your child watches TV or streams on a typical weekend day?
Hours your child uses a computer on a typical week day?
Hours your child uses a computer on a typical weekend day?
Hours your child plays computer games on a typical week day?
Hours your child plays computer games on a typical weekend day?
Do you think your child or teen has problems regulating their screen time?
Yes
No
Have you had to limit your child or teen's screen time?
Yes
No
Does your child or teen like to practice anything?
Yes
No
If yes to practice anything, what do they like to practice? Alone or with others?
Does your child or teen play an instrument? If yes, what and how long played?
How many minutes of aerobic exercise does your child get each week?
Does your child or teen enjoy sports or competition?
Please Select
Yes
No
Sometimes
What sports does your child or teen engage in regularly?
Baseball
Basketball
Cross Country
Dance
Fencing
Field/Track
Football
Golf
Gymnastics
Hiking
Hockey
Lacrosse
Martial Arts
Rock Climbing
Rugby
Running
Skiing
Snow Board
Soccer
Softball
Swimming
Tennis
Volleyball
Water Polo
Running
Never liked competition
Never liked team sports
Other
What extracurricular activities does your child or teen do?
Any other information you think we should know about your child or teen?
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