Child Psychosocial

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The information in this form is very important to your counselor, who will be reviewing it with you. It is also very important to the success of your treatment that your counselor understands as much about you as possible. Please answer the questions as honestly as you can, and feel free to explain or add any other information. This information, like all other information you give us, is confidential. If a question does not apply to you or your situation, please write N/A.

If English is not your primary language, or if you have any vision, reading, or writing problems, which might make filling out this form more difficult, please tell a staff member, who will arrange for someone to help you.

IDENTIFICATION

Which best describes you?*

Office Location*

Who referred you to Renewal?*

Parent/Guardian's First Name*

First

Parent/Guardian's Last Name*

Last

Phone

Email*

Address*

Street Address City Michigan ZIP Code

Client's First Name*

First

Client's Last Name*

Last

Date of Birth*

Month

Day

Year

Age*

Gender*

Race*

Are the parents/guardian going to be involved in the child's therapy process?*

Religious Preference*

Do you want to use your faith as part of you and your child's mental health treatment?*

Does your child have any specific needs or preferences regarding their ethnic/racial origin?*

What's the name of your church or organization?*

What are they?*

CHIEF CONCERN

Check all that apply:*

Alcohol Use

Bed Wetting

Clumsy

Daydreaming

Destructive

Disobedient

Distractible

Drug Use

Eating Problems

Fearful

Fire Setting

Hallucinations

Head Banging

Homicidal Talk

Hurts Animals

Impulsive

Infantile

Irritable

Lacks Initiative

Legal Issues

Lying

Mean to Others

Overactive

Peer Conflict

Phobic

Poor Appetite

Poor Concentration

Rocking

Running Away

School Performance

Self-Harm

Sexual Trouble

Short Attention Span

Shy

Sickly

Sleeping Problems

Slow

Soiled Pants

Stealing

Stomach Aches

Strange Behavior

Strange Thoughts

Stubborn

Suicide Talk

Temper Outbursts

Truancy

Very Unhappy

Withdrawn

How would you rate the severity of these behaviors?*

Not Serious

Serious

Very Serious

How long have these problems occurred?*

What are your expectations of your child?*

What changes would you like to see in your child?*

What changes would you like to see in yourself?*

What changes would you like to see in your family?*

CURRENT FAMILY SITUATION

Mother's First Name*

First

Mother's Last Name*

Last

Relationship to Child*

Marital Status*

How many years?*

Age*

Date of Birth*

Month

Day

Year

Race*

Place of Birth*

Highest Level of Education*

Occupation*

Father's First Name*

First

Father's Last Name*

Last

Relationship to Child*

Martial Status*

How many years?*

Age*

Date of Birth*

Month

Day

Year

Race*

Place of Birth*

Highest Level of Education*

Occupation*

Was the child adopted?*

Age of Adoption*

Adoption Date*

Month

Day

Year

What was the reason and circumstance of the adoption?*

LIVING SITUATION

What are the major family stressors at the present time? (If any)*

What are the major family strengths at the present time? (If any)*

What methods of discipline do you use on the child? (If any)*

What are the sources of income for the family?*

Does the child have siblings?*

List the child’s siblings. Click the + sign to list more than one.

Name

Age

Gender

School/Occupation

Grade

Living at home?

Current home living situation?*

Does the child share a room with someone else?*

With whom?*

How long has the child has had their own room?*

Does the child get along well with the members within the home?*

Please explain the circumstances.*

FAMILY HEALTH HISTORY

Excluding the child

List your family’s health history. Click the + sign to list more than one.*

(i.e., cancer, heart problems, Crohn's disease, etc.)

Name

Relation

Problem / Physical Health History

List all family members by their relation to the child who have had mental health symptoms. Click the + sign to list more than one.*

(i.e., anxiety, substance abuse, depression symptoms, mental retardation.)

Name

Relation

Problem / Physical Health History

Are there any other known health or mental health issues in the child’s family we should be aware of?*

Please explain:*

Does or did any member of the child's family have any problems with:*

Reading

Spelling

Math

Speech

None of the Above

Please explain:*

DEVELOPMENTAL HISTORY

Prenatnal

Pregnancy*

Normal Pregnancy*

Did the mother receive prenatal care during pregnancy?*

Was the mother ill or upset during pregnancy?*

Please explain:*

Did the father support and accept the pregnancy?*

Was the child exposed to alcohol, tobacco, and/or other substances during pregnancy?*

Please explain:*

Birth

Delivery Type*

Birth Weight*

Did the child arrive on time?*

How early and what was the reason?*

How late and what was the reason?*

Does the child experience any hearing problems?*

Does the child experience any visual problems?*

Please explain:*

Does the child experience any speech problems?*

Has the child received the most current immunizations?*

Please explain:*

Newborn

Normal Weight?*

How Long:

Breast Fed?*

How Long:

Colic?*

How Long:

Convulsions?*

How Long:

Difficulty Breathing?*

How Long:

Irritability?*

How Long:

Vomiting?*

How Long:

Development Milestones

Sat Up:*

Crawled:*

Walked:*

Weaned:*

Spoke Single Words:*

Spoke Sentences:*

Potty Trained:*

Dry Through Night:*

Early Social Developments

Relationship to Siblings and Peers:*

Describe special habits, fears, or idiosyncrasies of the child:*

EDUCATIONAL HISTORY

What grade is the child currently attending?*

Did the child skip a grade?*

Did the child repeat a grade?*

Which grade?*

Child’s Attending Class Type:*

Child’s Learning Style:*

Does the child have any specific learning disabilities?*

Has the child ever had a tutor or other special help with school work?*

Does the child attend school on a regular basis?*

Does the child appear motivated for school?*

Has the child ever been suspended or expelled?*

ACADEMIC HISTORY

Highest grade on report card?*

Lowest grade on report card?*

Favorite Subject?*

Least Favorite Subject?*

Any dramatic changes in grades recently?*

Does the child participate in extracurricular activities?*

Please explain:*

How many friends does the child have?*

What are the child’s educational dreams and goals?*

Does the child have an IEP or 504 Plan?*

Please explain:*

OTHER HISTORY

List the child’s special interests, hobbies, skills:*

Has the child ever been employed?*

When?*

Where?*

How long?*

What position?*

Has the child ever had any legal involvement?*

Please explain:*

Has the child ever appeared in juvenile court?*

Please explain:*

Has the child ever been on probation?*

Probation Start Date*

Month

Day

Year

Probation End Date*

Month

Day

Year

Reason?*

Probation Officer's Name*

Officer's Phone*

MENTAL HEALTH HISTORY

Has the child received outpatient counseling services before?*

Please complete the following: (Click the + sign to list more than once.)*

When

Where

Issues

Diagnosis (if known)

Has the child been admitted to a psychiatric hospital before?*

Please complete the following: (Click the + sign to list more than once.)*

When

Where

Issues

Diagnosis (if known)

Has the child ever acted violently towards others?*

Towards whom?*

Has the child ever thought of seriously hurting someone else?*

What was the child's plan and when?*

In the past month, has the child wished they were dead or wished they could go to sleep and not wake up?*

In the past month, has the child actually had any thoughts about killing themself?*

In the past month, has the child thought about how they might do this?*

In the past month, has the child had any intention of acting on these thoughts of killing themself? (As opposed to them having the thoughts, but they definitely would not act on them.)*

In the past month, has the child started to work out, or actually worked out, the specific details of how to kill themself and did they intend to carry out their plan?*

In the child's lifetime, has the child ever done anything, started to do anything, or prepared to do anything to end their life?*

Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed their mind or it was grabbed from their hand, went to the roof but didn’t jump; or actually took pills, tried to shoot themself, cut themself, tried to hang themself, etc.

Did they do any of these things in the past 3 months?*

What did they do?*

Has the child ever attempted to commit suicide?*

Last Attempt

Month

Day

Year

Number of Attempts*

Method(s) of Attempt*

Did any of the attempts lead to hospitalization?*

Which hospital and when?*

ABUSE HISTORY

Has the child been abused at any point of their life?*

If you were abused or witnessed abuse, please complete the following information: (Click the + sign to list more than once.)*

Age

Kind of Abuse

By Whom?

* Kinds of Abuse Legend: P = Physical, harsh touch / S = Sexual, such as touching/molesting, fondling or intercourse / N = Neglect, lack of shelter, food and/or protection / E = Emotional, such as humiliation, etc.

SUBSTANCE ABUSE HISTORY

Has the child ever used any type of drugs or alcohol?*

Alcohol

Order of Preference

First Use Age/Circumstance

Regular Use (Age/Amount/Freq)