Full name of person completing form:
Relationship to child:
Child's full name:
Preferred contact method:
Is child adopted?
If yes, at what age?
Has the child ever been hospitalized for mental health issue? (Include location, dates, length, and reason)
Has the child had previous mental health services? (If so, list agency, clinician, and periods of services)
Has the child seen a psychiatrist before? (If so, include location, clinician, diagnosis, and reason)
Has the child ever hurt themselves or attempted suicide? (Include details)
Child's Primary Care Physician:
What medications, herbs, vitamins, essential oils, or other over-the-counter medications does the child take? (Include name, dosage, prescriber, and what it treats)
List all medical diagnoses/struggles, including allergies:
Has the child ever had a head injury?
Has the child ever had a seizure?
Is the child pregnant?
Do the child's symptoms happen or worsen before their menstrual cycle?
Has the child ever been treated for chemical dependency/substance abuse?
Please check the box next to any substances used, and fill out the corresponding fields.
Who does the child play with?
What does the child do for fun?
Does the child have a spiritual or religious preference?
What is the reason for the child's appointment today?
Is there a history of trauma? (If so, please explain):
Is there a history of abuse? (If so, please explain):
Were there any difficulties during pregnancy and delivery with this child?
Were there any difficulties during the first year?
Has any parent had major medical problems?
Was the child diagnosed with colic as an infant?
Has the child had any head injuries or high fevers?
Did/does the child have delays in anything? (Crawling, walking, talking, etc.)
Has the child received any therapy? (Speech, occupational, physical, etc.)
Current academic performance (include if on IEP or 504)
Has the child ever been on medication to reduce activity level?
Has the child ever been on medication to improve concentration?
Has the child had digestive disturbance?
Does the child have hearing loss?
Does the child have vision loss?
When was the child's last medical exam?
Rate the child's overall activity level (High/Medium/Low):
Rate the child's overall tolerance for frustration (High/Medium/Low):
At what age was it noticed that this child was unusually active?
Has there been any change since then? (Explain the change, if any)
Does this child have a limit to how long he/she can play alone?
How well does this child play with others?
Can the child pay attention when playing a game with you?
Does the child change toys frequently?
Can the child complete a game with you?
Can the child complete a TV program?
When watching TV, does the child understand the program?
Is the child restless or active when watching TV?
Is the child disruptive when eating at the table with family members?
Is the child overly messy?
Would you consider the child to be any of the following: Restless, destructive, impulsive, distractible (If so, please list which)
Does the child have any nervous mannerisms? (tics, twitches, blinking, chewing lips/fingers)
Does the child have friends similar in age?
Does the child have difficulty keeping friends?
Does the child seem fearless or heedless to danger? (not worried about being hurt)
Has the school complained about the child's behavior?
Does the school report the same problems as you see at home?
Has the child been evaluated by the school?
Has the child been evaluated by medical personnel?
What types of consequences have you tried?
Have there been recent changes in the family?
Have there been any other changes at home?
Parent/Guardian's marital status:
Does the other parent have contact with this child?
If so, are there any problems with visitations?
Does the child get along with siblings?
Are any siblings being treated for or have been evaluated for:
Does this child require more reminders than their siblings?
Any other information you want the clinician to know?