Child / Adolescent / Testing Form (Child/Testing Intake) "*" indicates required fields Child / Adolescent / Testing Intake Background Data This questionnaire is to gather important background information on you that will assist us in providing you high quality care. Please answer the following questions to the best of your ability.Date* MM slash DD slash YYYY Name* Date of Birth* DD slash MM slash YYYY Gender Identity* Male Female Transgender MTF FTM Gender Neutral Non-Binary Additional category (please specify)* Parent or Parents (or Persons completing this form) Name* Family’s Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Address* Telephone Number (s):Mobile*Home*Work*Insurance* Subscriber* ID Number* Carriers DOB* MM slash DD slash YYYY Briefly state your main concerns regarding this child at home, school and community settings:*Please note any specific questions you would like answered by this evaluation/Assessment:*Please indicate the outcomes or services you would like to result from this evaluation and or treatment:*FAMILY INFORMATIONBiological Father* Age*Highest grade completed* Does child live with this parent?* Yes No (Explain)* Adoptive Father* Yes No Biological Mother* Age*Highest grade completed* Does child live with this parent?* Yes No (Explain)* Adoptive Mother* Yes No If parents are separated or divorced, please indicate the date of divorce and describe present custody and visitation arrangements:***Please attach a copy of the custody order if one is presentPrimary language spoken at home* Ethnic/Cultural Identification* Does this child speak a second language? Yes No If so, how well does he speak it?* Fluently Limited List the names and information requested for all individuals living in the household (include siblings, stepparents, grandparents, etc.)*NameRelationshipAgeComments Add RemoveAre there any siblings living outside the home?* Yes No If yes, please explain and list names and ages:*Has any members of your family had learning or school related problems?* Yes No If yes, please explain:*Have any members of your family had behavior problems?* Yes No If yes, please explain*List any agencies and/or caseworkers involved with this child or your family*Please describe any social stressors or family situations that may be affecting this child (e.g. death of family member, divorce, etc.)*DEVELOPMENTAL HISTORYWas the pregnancy full-term (37 to 40 weeks)?* Yes No Was the pregnancy with this child normal?* Yes No If no, please explain*Was the labor and delivery normal?* Yes No If no, please explain*Check any of the following that occurred:* Induced delivery Medication to ease labor pains Forceps Cesarean section Suction Breech delivery Other Other Type* Check any of the following that occurred to the infant during or immediately following birth:Injury during delivery* Yes No Explain*Cord around neck* Yes No Explain*Cardiopulmonary distress* Yes No Explain*Needed oxygen (turned blue)* Yes No Explain*Had an infection* Yes No Explain*Birth defects* Yes No Explain*Incubation* Yes No Explain*Was given medications* Yes No Explain*Seizures* Yes No Explain*Jaundice* Yes No Explain*Explain any additional care this child needed*What was this child’s birth weight?* Rate this child’s overall development* Slow Normal Fast Please explain and note any concerns you had with this child as an infant*Indicate the age in which this child achieved the following milestones: (estimate if unsure)* Sat alone First Words Crawled Spoke short sentence (2 words together) Walked alone Began to read Ran well Toilet trained (day) Fed self with spoon Toilet trained (night) Tied shoes Scribbled with pencil Do you have any concerns concerning this child’s motor or physical development?* Yes No If yes, please explain*Do you have any concerns with this child’s speech or language development (e.g. stuttering, articulation difficulties, poor understanding, etc)?* Yes No yes, please explain*MEDICAL INFORMATIONHow is this child’s overall health?* Excellent Good Fair Poor Please list any emergency room services, surgeries or hospitalizations this child has received for physical or mental health conditions:*ReasonDateAgeComments Add RemoveDoes this child have any vision problems?* Yes No If yes, please explain*Does this child have any hearing difficulties?* Yes No If yes, please explain:*Please indicate whether or not this child has or has had any of the following conditions:Allergies* Yes No Comments*Asthma* Yes No Comments*Chronic illness (e.g. diabetes, etc.)* Yes No Comments*Seizures/Convulsions* Yes No Comments*Head Injuries* Yes No Comments*Loss of consciousness* Yes No Comments*High fevers (105 degrees or above)* Yes No Comments*Motor or vocal tics* Yes No Comments*Lead poisoning* Yes No Comments*Dizziness/blurred vision* Yes No Comments*Stomach pain* Yes No Comments*Bladder difficulties* Yes No Comments*Bowel problems* Yes No Comments*Ear infections (how frequent)* Yes No Comments*Broken bones* Yes No Comments*Sleep problems (please describe)* Yes No Comments*Frequent headaches* Yes No Comments*List any medications this child takes on a regular basis:MedicationDosageReason Add RemoveExplain any side effects this child experiences from the above listed medications:*Who monitors this child’s medication (list physician’s name and frequency of medication checks):*(please include any physician’s name and address that your child currently sees on the permission to release form)Check any of the following therapies/treatments this child currently receives. If these services were received in the past, write the date next to the treatment.* Speech and language therapy Occupational therapy Physical therapy Other: Music therapy Vision therapy Hearing therap Recreational therapy Has this child ever received a psychological or psychiatric evaluation?* Yes No If yes, when, by whom, and what was the outcome (diagnosis, treatment, etc.)?*Please attach a copy of the most recent evaluation report to this formCheck any of the following mental health or behavioral health services this child is currently receiving. If the child received these in the past, please list the date next to the service.* Inpatient hospitalization Outpatient services Family-based mental health Drug and alcohol services Medication management Partial hospitalization Wraparound services Residential treatment facility MH/MR case management Other: EDUCATIONAL INFORMATIONPlease list this child’s school experiences, including preschool/Head Start:Grade(s)School/CityComments Add RemoveHas this child ever repeated or skipped a grade* Yes No If yes, indicate which grade and reasons:*Describe this child’s academic and/or behavioral strengths at school:*Describe this child’s academic and/or behavioral weaknesses at school:*Does the school share similar concerns regarding this child?* Yes No If no, please explain:*Does this child presently receive any special services at school?* Yes No If yes, please describe:*Has the school listened to your concerns regarding this child?* Yes No If no, explain what you would have liked to be different:*Do you believe this child has made normal educational progress?* Yes No Do you think this child is in need of special education services?* Yes No Has this child had any prolonged absence from school?* Yes No If yes, explain:*Does this child like to go to school?* Yes No If no, explain:*Does this child have complaints about school?* Yes No If yes, explain:*Please provide any additional information regarding this child’s educational or school background.*SOCIAL INTERACTIONSDoes this child make friends easily?* Yes No If no, explain:*Does this child prefer to play alone?* Yes No If yes, explain:*Are this child’s friends:* Older Same age Younger Do other children seek this child’s friendship?* Yes No Describe this child’s social interaction skills:*ADDITIONAL INFORMATIONProvide information on this child’s interests:*List any activities this child dislikes:*What types of discipline are used with his child at home (indicate effectiveness):*Has this child been involved in any legal issues (e.g. probation)?* Yes No If yes, please explain:*Is this child able to complete age appropriate self-help skills (e.g. toileting, dressing, bathing)?* Yes No If no, please explain:*Write any additional comments regarding this child that may assist in this evaluation:*Signature of Parent/Guardian:*Date* MM slash DD slash YYYY Relationship to child:* Helping clients is our mission not only our profession!EmailThis field is for validation purposes and should be left unchanged.
