Parent or Guardian: Complete for child up to age 21
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Patient Date of BirthPatient GenderMaleFemaleOther/Prefer Not To Say/Gender NeutralPatient GradePre-K or LowerKindergarten123456789101112College FreshmanCollege SophomoreCollege JuniorCollege SeniorWhy are you seeing us? When did the issue(s) start?If your child has been given diagnosis, please list here:
Please include any therapy, including psychotherapy, cognitive-behavioral therapy (CBT), occupational, physical, speech, applied behavioral analysis (ABA) or other
Therapy history List all therapies he or she has participated in and include the dates (approximate) and whether still current.
Tutoring historyList all tutoring or extra help at school with dates (approximate) and whether still current.Birth HistoryPlease indicate any problems or delays with pregnancy, birth, or infancy. Birth Weight:Gestational age at birth:Birth:VaginalCaesarean SectionWas your child born premature?NoYesPrematurity is generally defined as < 36 weeks gestational age at birthWas your child born in the United States? YesNoList any abnormalities on newborn screening: List any known fetal exposure:Include drugs, tobacco, alcohol or known toxinsList any prenatal problems with mother or baby:List any special care newborn required:Ex: bili lightsChild's ethnicity:Child's race:
Surgical HistoryPlease list all surgeriesHospitalization historyPlease list all hospitalizationsSingle Line Text
Family historyPlease indicate family members with conditions checked in boxes aboveParent 1 NameParent 1 OccupationParent 1 Biological RelationshipMotherFatherGrandparentStepmotherStepfatherLegal guardian/otherParent 2 NameParent 2 Occupation Parent 2 Biological RelationshipMotherFatherGrandparentStepmotherStepfatherLegal guardian/otherIs your child in daycare?NoYesName of Daycare:Is your child in school? YesNoName of School:Please indicate the name of the school your child attends and any other schools if in a different district or sector (private or public)Has your child ever been retained or repeated a grade? NoYes
Explain other:How many days has your child missed this term, if any? SportsList any organized sports your child participates inExtracurricular activitiesList any clubs or organized activities your child enjoys Does your child live in more than one household? Ex: shared custodyNames of all adults in the household: Names and ages of other children in the household:List all indoor pets:List all outdoor pets: Explain any recent life changes:Ex: moving, new sibling, parent marriage, traumatic experience, new schoolMood TodayOn a scale of 1 (very bad) to 10 (very good), how is your child’s mood TODAY?Mood this WeekOn a scale of 1 (very bad) to 10 (very good), how has your child’s mood been in the past WEEK?Mood this MonthOn a scale of 1 (very bad) to 10 (very good), how has your child’s mood been in the past MONTH?AppetiteWhat has your child eaten for his or her past three meals? MedicationsPlease list all medications, including prescription and OTC, with dose and reason for taking Submit
