Child Information Form
Child’s Name_________________________ DOB _____________________ Age
__________
Address _____________________________ City___________ State______
Zip___________
Home Phone _________________________ Cell Phone
_______________________________
Birthplace ___________________________ Race/Ethnicity
___________________________
Name of School _______________________________ Present Grade
____________________
Teacher(s)
Parent/Caregiver ______________________________
DOB _______________ Phone _____________________
Add’l Phone ____________________________________
Address _________________________________________
City ____________________ State _____ Zip_________
Race/Ethnicity _________________________________
Occupation _____________________________________
Marital Status __________________________________
Parent/Caregiver ______________________________
DOB _______________ Phone _____________________
Add’l Phone ____________________________________
Address _________________________________________
City ____________________ State _____ Zip_________
Race/Ethnicity _________________________________
Occupation _____________________________________
Marital Status __________________________________
___________________________________
_________________________________
Household Members
Name
DOB/Age
Relationship to
Child
Household Members of 2nd Household (if applicable)
Name
DOB/Age
Relationship to
Child
1
Occupation/Grade
Occupation/Grade
Religious, Cultural, or Spiritual Background of child and/or family members:
__________________________________________________________________________
____
Describe your child’s strengths
___________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________
Describe the reason for seeking help
_______________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________
When did these problems begin
___________________________________________________
Did you have any concerns about your child’s early development ☐ Yes
☐ No
If yes, please check:
☐ Feeding ☐ Sleeping ☐ Walking ☐ Talking
☐ Toilet Training ☐ Other
Briefly explain:
________________________________________________________________
Has your child had any significant medical problems?
If yes, please list:
Medical Problem
Date Began
☐ Yes
☐ No
Ongoing or Resolved
Has your child ever had psychotherapy or counseling?
☐ Yes
If yes, when/where/how long
_____________________________________________________
☐ No
Has your child ever been hospitalized for a psychiatric problem? ☐Yes
If yes, when/where/how long
_____________________________________________________
Has your child ever received psychological or educational testing? ☐ Yes ☐ No
If yes, when/where
_____________________________________________________________
2
☐ No
Has your child ever been prescribed medication for emotional or behavioral
difficulties?
☐ Yes
☐ No
If yes, please list all medications, dosages, and when child took them:
__________________________________________________________________________
____
Please list any medications your child is currently taking:
Medication
Amount
Frequency
What for
Please list any and all of child’s allergies
____________________________________________
__________________________________________________________________________
__________________________________________________________________________
________
Child Behavioral Checklist
Please check the things your child does:
Grooming
o
o
o
o
Brushes Teeth
Dresses self
Washes hands and face regularly without prompting
Bathes self regularly without prompting
Health Habits
o Good appetite
o Eats well-balanced diet
o Exercises regularly
o Likes sports
o Safety conscious
o Sleeps well
Responsibility
o Cleans room without prompting
o Does chores
o Trustworthy
o Completes homework
3
o Good student
o Has a job
Attitude (mood/self-esteem)
o Usually in a good mood
o Has fun/enjoys self
o Self-confident
o Likes self
Social Skills
o
o
o
o
o
Is polite
Makes friends
Plays fairly
Shares
Takes turns
Please let me know about some of the difficulties your child has:
School Learning Problems
o Poor arithmetic skills
o Poor expressive writing skills
o Poor reading skills
o Poor speech articulation
o Poor vocabulary
o Speaks in simple or unusual sentences
o Misunderstands others’ speech
o Poor printing or handwriting
o Poor hand-eye coordination
(315.40)
o Clumsiness
(315.10)
(315.80)
(315.00)
(315.39)
(315.31)
(315.31)
(315.31)
(315.40)
(315.40)
Inattention and Hyperactivity
(314.0x)
8/14
o Fidgets and squirms
o Difficulty staying seated
o Easily distracted
o Difficulty awaiting turn in games
o Often blurts out answers to questions before they have been completed
o Difficulty following directions (e.g. uncompleted chores)
o Difficulty sustaining attention
4
o
o
o
o
o
o
Often shifts from one uncompleted task to another
Difficulty playing quietly
Often talks excessively
Often interrupts or intrudes on others (e.g. butts into children’s games)
Often loses things necessary for task or activities at school or home
Often does dangerous activities without considering possible
consequences
Have these symptoms lasted at least 6 months?
☐Yes
☐No
Did these symptoms begin before age 7?
☐Yes
☐No
Defiant and Oppositional Behavior
(313.81) 4/9
o Often loses temper
o Often argues with adults
o Often actively defies/refuses adult requests/rules (e.g. refuses to do
chores at home)
o Often deliberately does things that may annoy other people
o Often blames others for his/her own mistakes
o Is often touchy or easily annoyed by others
o Is often angry and resentful
o Is often spiteful or vindictive
o Often swears or uses obscene language
Have these symptoms lasted at least 6 months?
☐Yes
☐No
Misconduct
3/13
(312.01)
o Has stolen without confrontation of a victim on more than one occasion
(including forgery)
o Has runaway from home overnight at least twice while living in parent’s
home (or once without returning)
Often lies
Has deliberately engaged in fire-setting
Is often truant from school or absent from work
Has broken into someone else’s house, building or car
Has deliberately destroyed other’s property (other than fire-setting)
Has been physically cruel to animals
Has forced someone into a sexual activity
Has used a weapon in more than one fight
Often initiates physical fights
Has stolen with confrontation of a victim (e.g. mugging, purse-snatching,
extortion, armed robbery)
o Has been physically cruel to people
Have these symptoms lasted at least 6 months?
☐Yes
☐No
o
o
o
o
o
o
o
o
o
o
Anxiety
(313.00) 4/7
5
o
o
o
o
o
o
o
Worries a lot about the future
Worries a lot about his/her past behavior
Concerned about athletic, academics, or social competence
Complains of aches and pains (e.g. headaches or stomachaches)
Very self-conscious
Needs a lot of reassurance
Often feels tense and unable to relax
Have these symptoms lasted at least 2 weeks?
☐Yes
☐No
Separation Anxiety
(313.21) 4/7
o Worries that something terrible might happen to his/her parents or
worries that they might not return
o Worries that something terrible might happen to separate the child from
parents
o Refusal to go to school in order to stay with parent
o Follows or clients to parent
o Nightmares about separation from parent
o Physical symptoms (e.g. headaches, stomachaches) on school days
o Becomes upset when parent about to leave
o Frequent request to call or return home when separated from parents
Have these symptoms lasted at least 2 weeks?
☐Yes
☐No
Social Behavior
o Shy and avoids strangers
o Does not respond to people
299.00)
o Overly affectionate with strangers
909.89)
o Fearful of adults
(313.21, 313.89, 299.00)
(313.89,
(313.89,
(313.21, 309.89)
High-Risk Behavior
o Has threatened and attempted suicide
o Has threatened or attempted to injure others
o Abuses alcohol or drugs
o Is sexually active
o Ran away
(300.40) 1st + 2nd/last 6
Depression
o Feels sad and depressed
o Doesn’t eat enough or eats too much
o Doesn’t sleep enough or sleeps too much
6
o
o
o
o
Low energy
Low self-esteem
Poor concentration or difficulty making decisions
Feelings of hopelessness
Eating Problems
o Is very underweight
(307.10)
o Eats too much
(307.51)
o Vomits often
o Swallows non-food objects
(307.51)
(307.5x)
Soiling and Bed-Wetting Problems
o Soils clothing
o Wets bed at night
o Wets underwear during the day
(307.70)
(307.60)
(307.60)
Speech Problems
o Speech is hard to understand
(307.00, 315.39)
o Speech doesn’t make sense
(307.00)
o Speech is too fast
(307.00, 313.00)
o Speech is too slow
(300.40)
o Stuttering
(307.00)
o Refuses to talk
(313.23)
o Makes unusual noises (e.g. barks, grunts, screams, yelps, or snorts)
(307.2x)
Control of Muscles and Bodily Movements
o Uncontrollable movements of arms, hands, legs, face, or head
(307.2x)
o Constant rocking
(307.30)
o Head-banging
(307.30)
o Puts objects in mouth
(307.30)
o Bites nails
(307.30, 313.00)
o Picks at skin
(307.30)
Is anyone in the home or family currently experiencing any major medical issues?
☐Yes ☐No
Explain
______________________________________________________________________
7
Is anyone in the home or family currently experiencing any legal issues?
☐Yes ☐No
Explain
______________________________________________________________________
Are there any significant stressors in the child’s home or family (e.g. separation,
major financial concerns, moving, addiction, etc.)?
☐Yes ☐No
Explain
______________________________________________________________________
Has anyone in the child’s family had a problem with drugs or alcohol?
☐Yes ☐No
Explain
______________________________________________________________________
Has anyone in the child’s family attempted or completed suicide or homicide?
☐Yes ☐No
Explain
______________________________________________________________________
Has the child witnessed or experienced anything that might be scary or
uncomfortable?
☐Yes ☐No
Explain
______________________________________________________________________
Has your child had difficulties at school?
☐Yes ☐No Explain
______________________________________________________________________
Does your child have an IEP?
☐Yes
☐No
If yes, please list date (month/yr) IEP began and any special services your child
receives:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
____________
Has your family had any contact with Child Welfare Services?
☐Yes ☐No
Explain
______________________________________________________________________
8
Any other information you would like me to know about your child/family:
_______________
__________________________________________________________________________
__________________________________________________________________________
________
Signature: ___________________________________________ Date:
____________________
9