_________________________________ Nickname: _____________________________ Age of first concern about your child/teen? __________________________________________ Who has raised concern? Parent, teachers other etc. ___________________________________

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v o v o psychiatric v o

v o therapies, tutoring, or

Birth & Past Medical History (circle and/or list)

Complications No-complications Full term Preterm

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Family Medical History: circle all that apply: Married Divorced Never Married Separated

If Divorced circle all that apply - joint custody sole custody joint medical decision-making

sole medical power of attorney

If divorced is there ongoing legal conflict? Yes No Has custody been finalized? Yes No

Siblings (Names and Ages) list any significant problems of learning, development or behavior:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

If CHILD IS ADOPTED Indicate medical and psychiatric history for biological parents here:

Biological Mother: __________________________________________________________

Biological Father: ___________________________________________________________

Mother: Age ____ Employer/Occupation: ________________________________________

Educational Level: High School AA College Degree Graduate Degree

(Indicate Yes or No, if Yes please describe)

Learning Disabilities: Yes No

ADHD: Yes No

Anxiety: Yes No

OCD: Yes No

Depression: Yes No

Tics: Yes No

Bipolar: Yes No

Other psychiatric illness or concern: ________________________________________________

Therapy: Yes No, if Yes describe: __________________________________________________

Medication: Yes No, if Yes describe: _______________________________________________

Extended maternal family history (your parents, siblings, nieces, nephews) – list any significant

problems of learning, development or behavior: ______________________________________

______________________________________________________________________________

Father: Age___ Employer/Occupation: ______________________________________________

Educational Level: High School AA College Degree Graduate Degree

(Indicate Yes or No, if Yes please describe)

Learning Disabilities: Yes No

ADHD: Yes No

Anxiety: Yes No

OCD: Yes No

Depression: Yes No

Tics: Yes No

Bipolar: Yes No

Other psychiatric illness/concern: __________________________________________________

Therapy: Yes No, if Yes describe: __________________________________________________

Medication: Yes No, if Yes describe: _______________________________________________

Extended paternal family history (your parents, siblings, nieces, nephews) – list any significant

problems of learning, development or behavior: ______________________________________

______________________________________________________________________________

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Educational History of Child/Teen

Mark response and provide detail where indicated

Qualified for Early Steps: ___Yes ___No

Birth- 3 yrs. – Preschool – Problems: ___Yes___ No if Yes list:

Qualified for Child Find: ___Yes ___No

3yrs-5 yrs.- Preschool and PreK- Problems: ___Yes___ No if Yes list:

Elementary School- Name(s): ______________________________________________________

IEP: ___Yes ___No, if Yes what eligibility and services:

Middle School - Name(s): _________________________________________________________

IEP: ___Yes___ No, if Yes what eligibility and services:

High School - Name(s): ___________________________________________________________

IEP: ___Yes___ No, if Yes what eligibility and services:

THANK YOU!

Signed: ____________________________________________________ Date: __________

Printed Name: _____________________________________________________________

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Anything else you would like us to know?