Child & Adolescent
Please complete this form prior to your first session.
Child and Adolescents
Child Development:
Patient Name:
*
First Name
Last Name
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
This section requires parental / guardian input
Pregnancy
Planned
Unplanned
Normal
Complications
Premature
Stressors during pregnancy:
If applicable, specify stressors during pregnancy
Delivery:
Natural
Prepared
Unprepared
Difficult
Labor was
blanks
hours. Birth weight
blank
.
Complications
Prenatal
Perinatal
Post-Natal
Developmental/Post Natal Difficulties:
Weight gain
Eating
Sleeping
Delays
Crawling
Walking
Toilet Training
Speech and Language
None
Other
Current Problems:
Problem
N/A
Past
Present
Comments
Parent/Child Conflict
Sibling/Peer Conflict
Attention Seeking
Temper Tantrums
Nightmares
Lying
Aggressive Behavior
Cruelty to Animals
Fire Setting
Running Away
Stealing/Shoplifting
Substance Use
Self-harm
Child's School:
Grade:
Is your child involved in special education classes?
Yes
No
Has your child had any suspensions/expulsions/poor conduct reports?
Yes
No
Does your child get along with teachers and peers?
Yes
No
Any areas of concerns with Academic Performance or homework completion?
Yes
No
Please expand upon current academic and peer concerns:
Submit
Should be Empty: