Child and Adolescent Developmental History Form

Capital Psychology Consultants

3050 Highland Oaks Terrace #1 Tallahassee, Florida 32301

850-224-5801

Child's Name

DOB

Full Address (Including City, State, Zip Code)

Phone

Name of person filling in form

Who has legal custody of the child ?

Please list names and ages of brothers/sisters or other children in the family

What are your current concerns about this child?

If not full term, how early and were there any complications?

What was the child's birth weight?

Problems during infancy period Please check off any areas where your child had problems

Did not enjoy cuddling

Was not calmed by being held/stroked

Difficult to comfort

Colic

Excessive restlessness

Excessively irritable

Diminished sleep

Frequent head banging

Constantly into everything

Developmental Milestones Please check off any milestones that were delayed

Crawled

Walked

Spoke first words

Spoke phrases

Spoke Sentences

Potty trained

Did the child wet the bed?

Named colors

Began to read

Other medical issues

Please list any other medical issues your child has had or explain answers above

List the medications your child is currently taking

Behavioral Health Evaluation History

If your child has been evaluated in the past, please list for what reason, by who, and the overall findings.

Please list any medications your child has taken for a behavioral health problem

Has your child been in a psychiatric hospital? Please list where, when, and for what reason

Child's Current School

Child's Current Grade

Has your child repeated any grades?

Does your child have an IEP or 504 Plan? If yes, for what?

Describe any problems your child may have at school?

Describe any problems your child has completing homework

Is there any family history of psychiatric problems, learning, behavior, or other problems on either father's or mother's side?

What do you typically do at home to try to manage your child?

Are there any significant differences between parents or households related to rules or discipline?

Has your child experienced any significant traumas or negative experiences that might affect them emotionally or behaviorally?

Please describe any strengths, talents, skills, or accomplishments of your child

Date field

Insurance ID Number

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Child and Adolescent Developmental History Form

Capital Psychology Consultants

Capital Psychology Consultants

Marie Guilford, Ph.D.