Child Background Form

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Child Background Form

This information you give below is for professional use only.
Note: The following form is likely to take 30-60 minutes to complete. Before beginning, please scroll through the form to make sure you have access to the necessary information (the form must be completed in one sitting).

Date

Child's Name

Gender

Address

City:

State

Zip

Birthdate

Age

School

Grade

Parent/Custodial Caretaker #1

Father

Mother

Other

Name

Birthdate

Age

Address

City

State

Education

Employer

Zip

Phone(H/C)

Occupation

Business Phone

Parent/Custodial Caretaker #2

Father

Mother

Other

Name

Birthdate

Age

Address

City

State

Education

Employer

Person filling out form

Primary Contact Person

Zip

Phone(H/C)

Occuation

Business Phone

Referred By

Phone

If applicable

Stepmother's Name

Birthdate

Age

Address

City

State

Education

Employer

Zip

Phone(H/C)

Occupation

Business Phone

If applicable

Stepfather's Name

Birthdate

Age

Address

City

State

Education

Employer

Emergency contact (other than primary)

Zip

Phone(H/C)

Occupation

Business Phone

Phone

In your own words, what are the problems or difficulties your child/adolescent is experiencing that led you to request an evaluation and/or treatment?

Comments/details:

When did these problems first begin?

What important things have happened to your child or the family the last six months?

What changes have you noticed recently in your child’s behavior and moods or in family members?

Has your child experienced any form of trauma (physical/sexual/emotional)?

Have you tried to get any previous help for any of the above concerns?

What kind?

Was this helpful? How/How not?

What other approaches have you tried on your own?

BIO-MEDICAL AND DEVELOPMENTAL HISTORY

List any physical/medical conditions or complaints that affect your child’s functioning now:

Were there any other physical/medical issues in the past?

What has your child been hospitalized for in the past? If so, when?

Were there any other physical/medical issues in the past?

How much did he/she weigh at birth?

At what age did your child:

Sit Alone:

Walk Alone:

Become toilet trained:

Say his/her first word:

Use two words together:

Dress himself/herself:

What accidents/injury has your child had?

Child’s Primary Physician

Other Specialist Seen

Phone

Medications: please list the following information for all medications and/or supplements taken

Name 1

Dosage 1

Start Date 1

Who prescribes 1

Purpose of medication 1

Name 2

Dosage 2

Start Date 2

Who prescribes 2

Purpose of medication 2

Name 3

Dosage 3

Start Date 3

Who prescribes 3

Purpose of medication 3

Name 4

Dosage 4

Start Date 4

Who prescribes 4

Purpose of medication 4

Name 5

Dosage 5

Start Date 5

Who prescribes 5

Purpose of medication 5

Name 6

Dosage 6

Start Date 6

Who prescribes 6

Purpose of medication 6

Name 7

Dosage 7

Start Date 7

Who prescribes 7

Purpose of medication 7

Name

Dosage 8

Start Date 8

Who prescribes 8

Purpose of medication 8

Name 9

Dosage 9

Start Date 9

Who prescribes 9

Purpose of medication 9

SCHOOL HISTORY

Which schools has your child attended since entering school?

In what three subjects does your child earn his/her best grades?

In what three subjects does your child earn his/her lowest grades?

Any repeated grades?

Current homeroom teacher

Child’s school performance

Above Average

Average

Below Average

What are his/her favorite subjects?

What special school problems does your child have?

What psychological or achievement tests has your child had previously?

What were the results and scores?

Are they on an IEP or 504 plan?

If so, for what reason?

**PLEASE BRING COPIES OF PRIOR EVALUATION REPORTS IF YOU HAVE ANY**

FAMILY HISTORY

What problems does your child have at home?

When are these problems worse?

When are they better?

Brothers Name 1

Brothers Birthday 1

Brothers Age 1

Brothers Grade 1

Brothers School 1

Brothers Name 2

Brothers Birthday 2

Brothers Age 2

Brothers Grade 2

Brothers School 2

Brothers Name 3

Brothers Birthday 3

Brothers Age 3

Brothers Grade 3

Brothers School 3

Brothers Name 4

Brothers Birthday 4

Brothers Age 4

Brothers Grade 4

Brothers School 4

Sisters Name 1

Sisters Birthday 1

Sisters Age 1

Sisters Grade 1

Sisters School 1

Sisters Name 2

Sisters Birthday 2

Sisters Age 2

Sisters Grade 2

Sisters School 2

Sisters Name 3

Sisters Birthday 3

Sisters Age 3

Sisters Grade 3

Sisters School 3

Sisters Name 4

Sisters Birthday 4

Sisters Age 4

Sisters Grade 4

Sisters School 4

Half-Brother 1

Half-Brother Birthday 1

Half-Brother Age 1

Half-Brother Grade 1

Half-Brother School 1

Half-Brother 2

Half-Brother Birthday 2

Half-Brother Age 2

Half-Brother Grade 2

Half-Brother School 2

Half-Brother 3

Half-Brother Birthday 3

Half-Brother Age 3

Half-Brother Grade 3

Half-Brother School 3

Half-Sisters Name 1

Half-Sisters Birthday 1

Half-Sisters Age 1

Half-Sisters Grade 1

Half-Sisters School 1

Half-Sisters Name 2

Half-Sisters Birthday 2

Half-Sisters Age 2

Half-Sisters Grade 2

Half-Sisters School 2

Half-Sisters Name 3

Half-Sisters Birthday 3

Half-Sisters Age 3

Half-Sisters Grade 3

Half-Sisters School 3

Stepbrothers Name 1

Stepbrothers Birthday 1

Stepbrothers Age 1

Stepbrothers Grade 1

Stepbrothers School 1

Stepbrothers Name 2

Stepbrothers Birthday 2

Stepbrothers Age 2

Stepbrothers Grade 2

Stepbrothers School 2

Stepbrothers Name 3

Stepbrothers Birthday 3

Stepbrothers Age 3

Stepbrothers Grade 3

Stepbrothers School 3

Stepsisters Name 1

Stepsisters Birthday 1

Stepsisters Age 1

Stepsisters Grade 1

Stepsisters School 1

Stepsisters Name 2

Stepsisters Birthday 2

Stepsisters Age 2

Stepsisters Grade 2

Stepsisters School 2

Stepsisters Name 3

Stepsisters Birthday 3

Stepsisters Age 3

Stepsisters Grade 3

Stepsisters School 3

Who lives in the house with your child at present?

How many bedrooms are there?

What are the sleeping arrangements?

Does your child regularly spend time in another home? If so, where and how often?

Who disciplines the children and how?

What year were your child’s parents married?

If divorced, please indicate date

What is the current custodial arrangement if parents are not married to one another?

What communication problems have there been between the parents?

Were they any previous marriages for the father?

Date of Marriage 1

Name of Spouse 1

Date of Divorce 1

Date of Marriage 2

Name of Spouse 2

Date of Divorce 2

Were there any previous marriages for the mother?

Date of Marriage 1

Name of Spouse 1

Date of Divorce 1

Date of Marriage 2

Name of Spouse 2

Date of Divorce 2

Any subsequent marriages for the father?

Date of Marriage 1

Name of Spouse 1

Date of Divorce 1

Date of Marriage 2

Name of Spouse 2

Date of Divorce 2

Any subsequent marriages for the mother?

Date of Marriage 1

Name of Spouse 1

Date of Divorce 1

Date of Marriage 2

Name of Spouse 2

Date of Divorce 2

What psychological difficulties or developmental disorders exist in the child’s family?

What troubles has your child or child’s family had with the law?

What religion is the family?

What sort of neighborhood does your child live in?

SOCIAL CHARACTERISTICS

What are your child’s strong points or favorable characteristics?

What are the “good” behaviors your child engages in?

What games or particular interests does your child enjoy?

What structured activities (e.g. sports, band, scouts, etc.) does your child do?

What kinds of things might serve as rewards for your child?

What people has your child felt closest to in his/her life?

How does your child get along with:

Parents

Teachers

Siblings

Peers/schoolmates

How many friends does your child have

Do you have any concerns about your child’s social functioning?

What other information would you like to share with us?

Thanks for submitting!

CORDELL
ASSOCIATES, LLC

(937) 276-3356

admin@mycordell.com

Marcy J. Gunn, Psy.D

Owner/Director of Child Psychology

Jonathan M. Cleveland, Ph.D.

Director of Adult Psychology

Chelsae Roby Pistello, Psy.D

Licensed Clinical Psychologist

FORMS