New Patient Form Parchment – Child (Parent please complete) Child's Name* Birth Date* MM slash DD slash YYYY Age* Biological Sex* Preferred Gender Pronoun Gender Identity* Questionnaire filled out by:* Father Mother Both Other If other please specify Presenting ProblemsWhat are your concerns regarding your child at this time?*In addition to the concerns expressed above, please check each symptom below that applies to your child and rate each symptom checked with a measurement of severity. (Scale of 1 to 10: 1 = minimally problematic, 10 = extremely problematic)Disturbing Thoughts* none 1 2 3 4 5 6 7 8 9 10 Specify types of thoughts if anySelf-Harming Behavior* none 1 2 3 4 5 6 7 8 9 10 Explain self harming behavior if anySuicidal Thoughts* none 1 2 3 4 5 6 7 8 9 10 Homicidal Thoughts* none 1 2 3 4 5 6 7 8 9 10 Fears/fearfulness* none 1 2 3 4 5 6 7 8 9 10 Specify fears/fearfulness if anySleep Difficulties* none Falling Asleep Waking Up Low Energy Specify fears/fearfulness if anyStress* none 1 2 3 4 5 6 7 8 9 10 Specify stress if anyGender Identity Issues* none 1 2 3 4 5 6 7 8 9 10 School/Work Problems* none 1 2 3 4 5 6 7 8 9 10 Specify school and work problems if anyFamily Problems* none 1 2 3 4 5 6 7 8 9 10 Specify type of family problems and individuals involved if anyAnger problems, oppositional and/or defiant behaviors* none 1 2 3 4 5 6 7 8 9 10 Specify anger problems, oppositional and/or defiant behaviors at home, school, or bothViolence* none 1 2 3 4 5 6 7 8 9 10 Specify violence type and toward whom if anyLegal Problems* none 1 2 3 4 5 6 7 8 9 10 Specify legal problems if anyOther Problems* none 1 2 3 4 5 6 7 8 9 10 Specify other problems if anyDevelopmental History for Children and AdolescentsPregnancy* Normal Illnesses Meds Bleeding Other If other, please specifyBirth* Full term Premature C-Section Complications Ages ofSupporting head Rolling over* Sitting* Crawling* Walking* First word* Feeding self* Toilet training* Adjustment problems* None Crying Stuttering Thumb sucking Nail biting Bedwetting Nightmares Excessive fears Tantrums Cruelty Jealousy Hyperactive Stealing Lying Shy Dependent Low self-confidence Mood swings Other If other please specifySocial DevelopmentHow many friends does your child have? How would you describe your child? Passive Assertive Dependent Independent Calm Anxious Happy Sad-depressed Trusting Suspicious Sensitive Calloused Conforming Rebellious Thoughtful Impulsive Inferiority Self-assured Serious Carefree Conventional Risk-taking Shy Outgoing Demanding Adaptable Selfish Considerate Detached Warm Mental Health History None Has your child received counseling in the past?* Yes No If yes, when, with whom, and for what reason?Medical HistoryWho is your child's Primary Care Physician?* Date of last visit* MM slash DD slash YYYY Describe any present or past health concerns/problems, including any traumas or surgeries.List all medications and dosages your child is currently taking.Height* Weight* Recent weight change* None Gain Loss Weight change in pounds Substance Use/Abuse HistoryAlcohol* None Past Present Frequency/Amount Drugs* None Past Present Frequency/Amount Nicotine* None Past Present Frequency/Amount Caffeine* None Past Present Frequency/Amount Has your child received treatment for any of the above substances?* Yes No If yes, when, for what substance and for how long?Are there any family members with substance abuse problems?* Yes No If yes, list relationship and substance abused.Family HistoryParent's marital status* Married Separated Divorced Other If divorced Number of times If married, how would you describe the quality/satisfaction of your marriage?If divorced, describe the custody arrangementsDescribe your relationship as parents (and step-parents if applicable) with your child.FatherMotherStep-parentSibling's Names / Sex / AgeDescribe your child’s relationship with his/her siblings.Is there any history of verbal, physical, or sexual abuse for your child?* Yes No If yes, please describe.Educational/Employment HistoryChild's current grade* School*Describe any learning disabilities/difficulties for your child.Describe any behavioral/discipline problemsDescribe your child’s relationship with peersIf employed, what job does your child hold and for how long?Legal HistoryNumber of arrests Number of substance-related arrests Number of OUIL, DUIL, or DWI arrests Nature of other arrestsOther legal concernsReligious/Spiritual BackgrounList any formal religious affiliation. Describe your child's involvementTherapist's Name*
