If you are human, leave this field blank.Background Information for ChildrenChild's NameToday's DateAgeGrade LevelDate of BirthLeft or Right Handed?Parent Information for Who is Completing the FormNameAgeSocial Security #Date of BirthAddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codePhoneAlternate PhoneWhere may we leave a phone or text message?Email address for receiving forms or brief communicationIn Case of an emergency please notify:NamePhoneRelationshipName of Referring Doctor for EvaluationName of Referring Doctor for EvaluationWill your child's evaluation be requested by anyone else besides the referring physician?YesNoWill your child's evaluation be requested by an attorney or used for legal purposes?YesNoIs there a history of this problem or a precipitating event?Was there a previous evaluation? If yes, with who and when?Which of the following are of concern at this time? (Check all that apply)DepressionAnxietyADHDTraumaAbuse/ViolenceBehavior ProblemsDevelopment ProblemsSubstance Use/AbuseHealth-RelatedSocial RelationshipsSuicide RiskEating DisorderSchool ProblemsFamily StatusMother's NameAgeOccupationFather's NameAgeOccupationLegal Guardian (If not parent)Parents Currently:MarriedSeparatedDivorcedNot MarriedIf Divorced, who has custody?MotherFatherBothOtherBoth parents living?YesNoIf no, please explain:List everyone in household(s)Sister(s) ageBrother(s) ageFamily HistoryPlease list any family history of medical problems:Please list any family history of mental health problems:Please list any family history of substance abuse problems:Please list any family history of legal problems:Developmental HistoryIs your child 12 years old or younger?If yes, please complete the Developmental History Questionnaire. If no, please complete the following information:Please list any complications or unusual birth circumstances or development concerns:Social HistoryPlease list any problems or concerns with social interactions:Does your child have a history of being bulled or bullying others? If yes, please provide details:What hobbies, sports, or clubs does your child enjoy?What coping strategies does your child currently use?Is your child dating currently or have a history of dating?What after school jobs has your child had?Health Status and HistoryCurrent or Chronic Health ProblemsCurrent medications, including over-the-counterAny history of hospitalizations (including dates/places/reason):Any history of surgeries or head injury:Mental Health Status and HistoryPrevious Counseling (including dates & places)Previous hospitalization for emotional or substance abuse problemsHistory of medications for emotional/substance abuse problemsEducation Status and HistorySchool AttendingWhat kinds of problems have teachers reported at school?What kinds of problems does your child report regarding school:Is there a history of a 504Plan or IEP? If yes, please provide specifics of the plan:Trauma/Abuse HistoryPlease list any history of Trauma:Has Department of Child Safety been involved with your child? If yes, please indicate the circumstances:Legal HistoryHas your child been in any kind of legal problem? If yes, please provide details:Substance Use (0=no use, 1=occasional, 2=moderate, 3=heavy, 4=addiction, 5=currently in treatment)AlcoholTobaccoCaffeineIllicit Drugs (specify)Past Use of Drugs (specify)Other ConcernsPlease list any other concerns not already noted above:Captcha *reCAPTCHA is required.Submit
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