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? ______________________________
__________________________________________________________________________________________
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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