Child and Adolescent Developmental History Form

Capital Psychology Consultants

3050 Highland Oaks Terrace #1 Tallahassee, Florida 32301

850-224-5801

Child's Full Name

DOB

Gender

Full Address (Including City, State, Zip Code)

Phone

Name of person filling in form

What is the marital status of parents (married, divorced, separated, never married)

What are the custody arrangements, if applicable?

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

Specific concerns that prompted this visit and how long you have had these concerns

Were you referred by anyone ? If so, who?

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

Did your child receive any intervention services for delays (Speech Therapy, Physical Therapy, Occupational Therapy)?

Medical history details

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

List any medications your child is currently taking

Educational History: Current School

Teacher's Name

Child's Current Grade

Teacher's Email address

If so, what grade?

Describe any problems your child may have at school or concerns you have about their education

Describe any problems your child has completing homework

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 in the past for a behavioral health problem

If medication was discontinued due to side effects please note what happened

Is your child currently seeing a psychiatrist or other practitioner for medication?

Please list the doctor or the agency

What medications is your child currently taking for behavioral health?

Is your child currently seeing a therapist?

Please list their name or the agency

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

Are there any recent changes or stressors for your child (moving, losses, divorce)

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

Has your child been in trouble with the law?

Are there any substance use/abuse concerns for your child?

Do the parents agree about the problems, or do they have different perspectives?

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

What is your child's personality like?

Does your child have any problems with social relationships?

What does your child like to do?

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

Is there any other information that you believe is important to know?

What are your main goals for this assessment/visit?

Insurance ID Number

Today's Date

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Child and Adolescent Developmental History Form

Capital Psychology Consultants

Capital Psychology Consultants

Marie Guilford, Ph.D.