New Beginnings Psychology Center, LLC 33 Walt Whitman Road, Suite 307 6 New York AvenueHuntington Station, NY 11746 Sound Beach, NY 11789631-423-3600 631-849-1300

CHILDREN / ADOLESCENT (Age 17 and under)SOCIAL / MEDICAL HISTORYBIOPSYCHOSOCIAL ASSESSMENT

Please answer all questions, do not write in boxes labeled psychologist’s use only. Thank you.

Child’s Name: _____________________________________________ Date: ____________________

Child’s age: ________ Date of Birth: ____/____/____ Sex (circle one): Male Female

Address: _________________________________________________________________________________ STREET

______________________________________________________________ _______________________________ _________________________CITY STATE ZIP

Phone: (Home) _____________________________ (Cell) ____________________________________

Person filling out form: ______________________________________________________________________

Name of person responsible for bill: ____________________________________________________________

Emergency Contact: ________________________ Relationship: _____________ Phone: ________________Parents / Stepparents

Mother’s name: _________________________ Age: ___ Education: _______ Occupation: ________________

Father’s name: __________________________ Age: ___ Education: _______ Occupation: ________________

Step-Father’s name: ______________________ Age: ___ Education: _______ Occupation: ________________

Step-Mother’s name: _____________________ Age: ___ Education: _______ Occupation: ________________

Marital status of parents: _________________ If parents are separated/divorced, how old was child at time of separation? _________________

With whom does the child live? ___________________________________________________

Custody: ☐Lives in one home with both legal parents. ☐Mother has physical custody. ☐Father has physical custody. ☐Physical custody is shared. ☐Other: ____________________

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List all people living in household:Name Age Relationship to child _____________

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If any brother(s) or sister(s) are living outside the home, list their names and ages.

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If any brothers / sisters are deceased please give name and year: ______________________________________

FAMILY INFORMATION:

Place of birth: ____________________________________________________

Childs Race: ☐African-American ☐Caucasian ☐Native American ☐Hispanic ☐Asian ☐Latino ☐Other (specify)_______________________________________________________

Was the child adopted? ☐Yes ☐No If yes, at what age? ___________ From Where? ___________________

Has the child ever been placed outside of the home? ☐Yes ☐No If yes, where? _______________________

In how many residences has the child lived since birth? ___________________________________________

Has the child been physically or sexually abused, assaulted or molested? ☐Yes ☐No ☐Don’t know

If yes, specify by whom and where ___________________________________________________________

Has child protective services ever been involved? ☐Yes ☐No If yes, please explain ___________________

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Have the child’s parents or any other family members had any mental health or emotional problems?

☐Yes ☐ No If yes, describe: _________________________________________________________________

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PRESENTING PROBLEM:

Briefly describe your child’s current difficulties: __________________________________________________

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How long has this problem been of concern to you? _________________________________________________

When was the problem first noticed? ____________________________________________________________

What seems to help the problem? ______________________________________________________________

What seems to make the problem worse? ________________________________________________________

Has the child received evaluation or treatment for the current problem or similar problems? ☐Yes ☐No

If yes, when and with whom? _________________________________________________________________

Is the child on any medication at this time? ☐Yes ☐No

If yes, list medications:____________ __________________________________________________________

How do you want your child’s situation to be different after coming here? ______________________________

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For Psychologist’s Use Only:Presenting Problem / History of Problem:

Symptoms:

Interview / Observation of child:

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SOCIAL AND BEHAVIORAL CHECKLIST

Place a check next to any behavioral, social, or physical problem(s) that your child currently exhibits.

☐ Has difficulty with speech ☐ Has frequent tantrums☐ Has difficulty with hearing ☐ Has frequent nightmares☐ Has difficulty with language ☐ Has trouble sleeping (describe)____________________☐ Has difficulty with vision ☐ Has blank staring spells☐ Has difficulty with coordination ☐ Rocks back and forth☐ Prefers to be alone ☐ Bangs head☐ Does not get along well with other children ☐ Holds breath☐ Is aggressive ☐ Eats poorly☐ Is shy or timid ☐ Is stubborn☐ Has poor bowel control (soils self) ☐ Is much too active☐ Trouble paying attention ☐ Is more interested in things (objects) than in people☐ Engages in behavior that could be dangerous to self (describe)_____________________________________

☐Other, please explain: ______________________________________________________________________

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Describe child’s relationship with his / her:

Father: ___________________________________________________________________________________

Mother: __________________________________________________________________________________

Sibling(s): _________________________________________________________________________________

Stepparent(s): _____________________________________________________________________________

OTHER INTERPERSONAL RELATIONSHIPS:How do you describe the child’s friendships:

☐ No Friends ☐ Only Acquaintances ☐ Both acquaintances and close friends

How many close friends? _______

What do friends do together? _________________________________________________________________

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Place a check next to any behavior or problem that your child currently exhibits.

☐ Has special fears, habits, or mannerisms ☐ Is Impulsive (describe)______________________________ ☐ Sucks thumb ______________________________________ ☐ Is slow to learn☐ Show daredevil behavior ☐ Other (describe): _______________________☐ Gives up easily _____________________________________☐ Wets bed _____________________________________

EDUCATIONAL HISTORY

School: _________________________________________ Grade:____________________________

Check:

☐ Has difficulty with reading ☐ Has difficulty with other subjects (please list):☐ Has difficulty with arithmetic ___________________________________________☐ Has difficulty with spelling ___________________________________________☐ Has difficulty with writing ___________________________________________☐ Does not like school

Is your child in a special education class? ☐Yes ☐No

If yes, what type of class? ___________________________________________________________________

Has your child been held back a grade ☐Yes ☐No

If yes, what grade and why? __________________________________________________________________

Has your child ever been suspended or expelled? ☐Yes ☐No

If yes, please describe: ______________________________________________________________________

Does your child have an IEP or 504 plan? ☐Yes ☐No

If yes, please explain: _______________________________________________________________________

DEVELOPMENTAL HISTORY

During pregnancy, was mother on medication? ☐Yes ☐No If yes, what kind? _________________________

During pregnancy, did mother smoke? ☐Yes ☐No If yes, how many cigarettes each day? _______

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During pregnancy, did mother drink alcoholic beverages? ☐Yes ☐No If yes, what did she drink? _________

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Approximately how much alcohol was consumed each day? ________________________________________

During pregnancy, did mother use drugs? ☐Yes ☐No If yes, what kind? ____________________________

Were forceps used during delivery? ☐Yes ☐No

Was a Cesarean section performed? ☐Yes ☐No If yes, for what reason? _____________________________

Was the child premature? ☐Yes ☐No If so, by how many months? _________________________________

What was the child’s birth weight? _____________________________________________________________

Were there any birth defects or complications? ☐Yes ☐No If yes, please describe: _____________________

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Were there any feeding problems? ☐Yes ☐No If yes, please describe: _______________________________

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Were there any sleeping problems? ☐Yes ☐No If yes, describe: ___________________________________

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As an infant, was the child quiet? ☐Yes ☐No

As an infant, did the child like to be held? ☐Yes ☐No

Were there any special problems in the growth and development of the child during the first few years? ☐Yes ☐No If yes, please describe: ___________________________________________________________

The following is a list of infant and preschool behaviors. Please indicate the age at which your child first demonstrated each behavior. If you are not certain of the age but have some idea, write the age followed by a question mark. If you don’t remember the age at which the behavior occurred, please write a question mark.

BEHAVIOR AGE BEHAVIOR AGEShowed response to parent Put several words togetherRolled over Dressed selfSat alone Became toilet trainedCrawled Stayed dry at nightWalked alone Fed selfBabbled Rode tricycleSpoke first word

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CURRENT HEALTH INFORMATION:

Describe child’s health generally: ☐Good ☐Fair ☐Poor Is the child sexually active? ☐Yes ☐NoIf yes, is the child on birth control? ☐Yes ☐No What kind? _______________________________________

List and health problems the child has had: _______________________________________________________

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Does the child have:

Current Immunizations ☐Yes ☐No Which are needed?_______________________

Any allergies ☐Yes ☐No Specify ________________________________

Appetite problems ☐Yes ☐No Specify ________________________________

Sleep problems ☐Yes ☐No Specify _______________________________

A Disability or handicap ☐Yes ☐No Specify ________________________________

Contagious or other diseases ☐Yes ☐No Specify ________________________________

Any accidents / injuries ☐Yes ☐No Specify ________________________________

Dental, vision or hearing problems ☐Yes ☐No Specify ________________________________

Any hospitalizations ☐Yes ☐No Specify ________________________________

Physician: _________________________________________________________________________________ Name City

Date of last contact: ____/____/____ Reason for last contact: _______________________________________

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SUBSTANCE USE / ABUSE:Please complete the chart below

Category of Drug

Has child ever used?

Currently using?

Age of first use?

How often does child

use?

How Taken? How much?

Use last 48

hours?

Withdrawal symptoms

Alcohol ☐Yes ☐No ☐Yes ☐NoStimulant ☐Yes ☐No ☐Yes ☐NoCocaine ☐Yes ☐No ☐Yes ☐NoTranquilizer ☐Yes ☐No ☐Yes ☐NoBarbiturate ☐Yes ☐No ☐Yes ☐NoMarijuana ☐Yes ☐No ☐Yes ☐NoOpioid ☐Yes ☐No ☐Yes ☐NoHallucinogen ☐Yes ☐No ☐Yes ☐NoPrescribed ☐Yes ☐No ☐Yes ☐NoNicotine ☐Yes ☐No ☐Yes ☐NoVape ☐Yes ☐No ☐Yes ☐NoCaffeine ☐Yes ☐No ☐Yes ☐NoOther ☐Yes ☐No ☐Yes ☐No

FAMILY MEDICAL HISTORY:Place a check next to any illness or condition that any member of the child’s family has had. When you check an item, please note the members relationship to the child.Check Condition Relationship to child Check Condition Relationship to child

Alcoholism DepressionCancer Learning disabilityDiabetes ADHDHeart trouble Mental RetardationBipolar Disorder SchizophreniaAnxiety Disorder Completed suicideAttempted Suicide Drug addictionOther

RELIGION / SPIRITUALITY:Religion: ☐Protestant ☐Catholic ☐Buddhist ☐Hindu ☐Jewish ☐Muslim ☐Atheist ☐Agnostic ☐Other: ___________________

LEGAL INFORMATION:Has the child ever: Had difficulty or contact with police? ☐Yes ☐No Appeared in juvenile conference? ☐Yes ☐No Been on probation? ☐Yes ☐No PINS petition? ☐Yes ☐NoPlease explain: __________________________________________________________________________

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OTHER INFORMATION:What are your child’s favorite activities?

1.__________________________________ 4.____________________________________

2.__________________________________ 5.____________________________________

3.__________________________________ 6.____________________________________

What activities would your child like to engage in more often than he/she does at present?

1.__________________________________ 2.____________________________________

What activities does your child like least?

1.__________________________________ 2.____________________________________

What disciplinary techniques do you usually use when your child behaves inappropriately? Place a check next to each technique that you usually use. There also is space for writing in any other disciplinary techniques that you use.

Check Disciplinary technique Check Disciplinary techniqueIgnore problem behavior Tell child to sit on chairScold child Send child to his or her roomSpank child Take away some activity or foodThreaten child Redirect child’s interestDon’t use any technique Other technique: (describe)__________

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Which disciplinary techniques are usually effective? _______________________________________________

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With what type of problem(s)? ________________________________________________________________

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Which disciplinary techniques are usually ineffective? ______________________________________________

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With what type of problem(s)? ________________________________________________________________

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What have you found to be the most satisfactory ways of helping your child? ___________________________

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What are your child’s assets or strengths? _______________________________________________________

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PREVIOUS COUNSELING / PSYCHOTHERAPY:Has your child ever been in counseling / therapy before? ☐Yes ☐No

Name of Provider Clinic Year Diagnosis / Problem

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Has your child been prescribed psychotropic medication? ☐Yes ☐No

MEDICATION DOSAGE PRESCRIBED BY

Reason:

Other medications currently prescribed:

MEDICATION DOSAGE PRESCRIBED BY

Reason:

Check if applicable: ☐Inpatient ☐Day Treatment ☐Substance Abuse Program ☐Psychological Testing ☐Partial Hospitalization

Explain any of the above: ____________________________________________________________________

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Has the child ever:

Made a suicide attempt: ☐Yes ☐No If yes, when? _____________________ Describe: ________________________________________ _______________________________________________

Expressed homicidal thoughts: ☐Yes ☐No Describe: ___________________________________ ___________________________________________

Had episodes of explosive anger: ☐Yes ☐No Describe: __________________________________ __________________________________________

Is the child currently expressing homicidal / suicidal feelings? ☐Yes ☐No

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Signature of Informant ______________________________________________ Date___________________

Relationship to client_______________________________________________________________________

Signature of Psychologist____________________________________________ Date___________________

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For Psychologist’s Use OnlySUICIDALITY / HOMICIDALITY:☐ Client denies any current suicidal or homicidal thoughts, feelings, gestures, intentions or plans.☐ Client reports current suicidal or homicidal feelings. Specify: _________________________________

_______________________________________________________________________________________☐ Client denies history of suicidal or homicidal thoughts, feelings, gestures, intentions, or plans.☐ Client has history of suicidal or homicidal thoughts, feelings, gestures, intentions, or plans.Specify: ________________________________________________________________________________

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MENTAL STATUS:General Behavior: cooperative, passive, withdrawn, dramatic, restless, hostile, anxious, other____________Attire: appropriate, seductive, untidy, loud, meticulous, other _____________________________________Gait: normal, erect, stooped, ataxic, rigid, shuffling, manneristic, other______________________________Motor Activity: normal, agitated, retarded, tremor, tic, mannerism, other ____________________________Stream of Thought: Productivity: spontaneous, verbose, pressured speech, unproductive, other _________________________ Progression: normal, loose, circumstantial, preservation, halting, blocking, incoherent, fragmented, Other _____________________________________________________________________ Language: normal, baby-talk, peculiar, expression, stilted, other _________________________________Emotional Tone & Reactions: Mood: normal, indifferent, fearful, angry, euphoric, labile, shallow, blunted, flat, composed, anxious, sad, tearful, depressed, other________________________________________________________ Affect: appropriate, inappropriate, other _____________________________________________________Mental Trent / Content of Thoughts: Perception: normal, auditory hallucination, visual hallucination, illusions, depersonalization, hypochondriasis, other_________________________________________________________ Orientation: normal, disoriented to time, place, person, other ____________________________________ Memory: normal, defective (remote, recent, immediate), other ___________________________________ General knowledge: consistent with education, inconsistent, able to abstract, concentrate, other ________ ____________________________________________________________________ Insight: absent, good, fair, minimal Judgment: good, fair, poor

DIAGNOSTIC SUMMARY:

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For Psychologist’s Use Only

DIAGNOSTICE IMPRESSIONS:

Axis I ____________________________________________________________________________

Axis II ___________________________________________________________________________

Axis III __________________________________________________________________________

Axis IV __________________________________________________________________________

Axis V (GAF) _____________________________________________________________________

For Psychologist’s Use Only

GOALS FOR TREATMENT:

1.

2.

3.

4.

5.

_________________________________________________________________________________________Psychologist’s Signature Date

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