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Parent Family Assessment

Parent Family Assessment

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Published by mpriceatccusa
Parent Family Assessment
Parent Family Assessment

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Published by: mpriceatccusa on May 16, 2013
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10/15/2013

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CONNECTIONSPARENT -
 
FAMILY ASSESSMENTPART A: CHILD/YOUTH HISTORYChild/Youth Name
 ______ 
 Assessment Date Parent/Guardian NameAssessment Location Client Home __________Edison _________Other _________
 
PRESENTING PROBLEM:
Current crisis with child/youth; history, duration, and possible precipitatingevents. 
CHILD DEVELOPMENTAL MILESTONES:
Comment on prenatal and birth history; infancy issues suchas: toilet training, walking, talking and developmental delays/difficulties; any substance use/abuse at thetime of conception or during the pregnancy. 
CHILD/YOUTH MEDICAL HISTORY:
 Are childhood immunizations up to date?____Yes___NoDate and reason for most recent visit to physician:Has the child had an eye exam?___Yes___NoHas the child had a hearing exam? ___Yes___No Any known allergies?___Yes___NoIf yes, explain: Any known medication allergies? ___Yes ___NoIf yes, explain:
 
 _____________ 
Indicate Child/Youth Medical History.Medical ProblemReference by NameTime FrameFrom – ToCurrent Status
 
2
 
CHILD BEHAVIORAL HISTORY:
Check appropriate box if behavior has been noticed. (For multiple children, indicate by putting name(s) in appropriate box.
Behavior DeniedPast
P
resent Comments: (Frequency, Duration)
1. Loses temper easily/Low frustration tolerance2. Run Away Behaviors3. Destructiveness/Vandalism4. Blames others for own mistakes5. Frequent Mood Shifts6. Angry/Resentful/Vindictive7. Over-Dependent Behaviors8. Defiant attitude9. Eating Difficulty/Disorder 10. Initiates fights/Provokes others11. Physically cruel to others12. Physically cruel to animals13. Stealing14. Lying15. Sexually Abusive to others16. Sexually acting out behaviors17. Arson/Firesetting18. Truancy19. “Cons” other people/ Manipulative20. Refuses/ignores adult requests21. Lack of Attention to tasks/Difficulty organizing tasks22. Hyperactive/Impulsivity23. Verbal Aggression24. Problems in School: Academic/Behavioral25. Homicidal Behavior 26. Sleep Disturbance27. Withdrawn/Shy28. Depression/Crying29. Suicidal Behavior 30. Enuresis: Repeated voiding of urine into bed or clothes31. Encopresis: Repeated passage of feces inappropriately.
CHILD BEHAVIOR HISTORY: (Continued)
EXPLAIN ALL SIGNIFICANT CONCERNS
3

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