Atlanta

Child Therapy, Inc.

BEHAVIORAL/MENTAL STATUS PROFILE
Clients Name: ______________________________________________

Date: _____________________

Name of Person Completing this form: ____________________________________________

The following questionnaire is to be completed by the parent or guardian. This form has been designed to provide necessary
information regarding the childs behavior and mental status. For each section, check all that apply.

BEHAVIOR
PHYSCIAL AGGRESSION
Does the child or has the child ever engaged in physically aggressive toward:
family

animals

Other: ___________________

school personnel

friends

Does the child or has the child ever had outbursts that result in:
biting

choking

kicking

hitting

pushing

grabbing

scratching

pinching

throwing of objects

other: ________________________
VERBAL AGGRESSION
Does the child or has the child ever made threats to:
self

friends

animals

family

other: ___________________
Does the child or has the child ever engaged in verbally aggressive behavior:
screaming/yelling

disrespectful tone/words

other: ________________________

mimicking of others

talking back

DISRUPTIVE BEHAVIOR
Does or has the child ever engaged in:
rages

lying

elopement

power struggles

provocation of conflict

problems with authority

other: _______________________

accepting limits/boundaries

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506

Atlanta Child Therapy, Inc.

UNLAWFUL BEHAVIOR
Does or has the child ever engaged in:
stealing

stealing

selling of illegal drugs

truancy

use of a weapon

robbery (armed/unarmed)

vandalism

abuse of prescription drugs

assault

destruction of property

illegal drug use

assault with the use of a weapon

other:_________________________
THEORY OF MIND
Does or has the child ever struggled to a significant degree with:
hyper-focusing on one interest

repetitive body movements/noises

difficulty in socializing

displaying rigid thinking

shifting from activity to another

awkward gait

other: ________________________
SENSORY SENSITIVITIES
Does or has the child ever displayed significant issues related to:
touch/feel

sound

light

smell

Does or has the child ever struggled to a significant degree in the following areas:
eating

gross motor

poor spatial relationships

spinning

pain (over/under sensitive)

Vertigo

carsickness

Dizziness

coordination

fine motor

Imbalance

other: _________________________

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506

Atlanta Child Therapy, Inc.

SOCIALIZATION
Does or has the child ever displayed significant issues related to:
making friends

considering others interests

difficulty sharing friends

keeping friends

taking perspectives

conflict resolution

starting/maintaining conversations

conversational turn taking

other: _______________________
EXECUTIVE FUNCTION
Does or has the child ever displayed significant issues related to:
goal setting

initiating boring tasks

sustaining effort

shifting focus

planning

accepting/using feedback

executing tasks

prioritizing

pacing work

self-correcting

completing tasks

self-monitoring

getting started

sequencing

other:______________________
TICS
Does or has the child ever displayed significant issues related to:
involuntary sounds (vocal tics)

involuntary body movements (motor tics)

___ for how long?

___ for how long?

___ age of onset

___ age of onset

___ transient or ___ continuous

___ transient or ___ continuous

Describe:
_________________________________________________

Describe:
________________________________________________

_________________________________________________

________________________________________________

_________________________________________________

________________________________________________

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506

Atlanta Child Therapy, Inc.

MENTAL HEALTH STATUS
ANXIETY
Does or has the child ever displayed significant issues related to:
worrisome thoughts

anxiety during transitions

fear of change

persistent self-doubt/self-criticism

worry about failure

school phobia/avoidance

fearing social situations

preoccupation with being embarrassed/humiliated

anxiety in unstructured activities

Isolation from peers

constantly seeking approval/reassurance

over reactive to small events

other: __________________________

being overly emotional/tearful

OBSESSIONS
Does or has the child ever displayed significant issues related to:
contamination fears

need to have things just right

getting stuck or thoughts/ideas

perfectionism

fear of harm to self or family

sexual obsessions

inflexibility

violent imagery

moral or religious preoccupation

other:___________________________

need for order/symmetry

FEARS & PHOBIAS

Does or has the child ever displayed significant issues related to:
germs

snakes

being abandoned

weather

dark

heights

insects

being alone

leaving home

other: ___________________________

death

illness

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506

Atlanta Child Therapy, Inc.

COMPULSIONS
Does or has the child ever displayed significant issues related to:
skin picking

washing/hygiene rituals

saving/hoarding

hair pulling

counting rituals

checking/rechecking

nail biting

touching rituals

repeating activities

other: _____________________

smelling rituals

scratching

SELF-INJUROUS BEHAVIOR
Does or has the child ever engaged in potentially dangerous behavior
ingestion of objects

refusal to eat

other: ________________________

purging

self-mutilation (cutting, etc.)

PSYCHOTIC BEHAVIOR
Does or has the child ever displayed significant issues related to:
visual hallucinations

nonexistent tactile sensations

auditory hallucinations

disorganized thoughts/speech

other: _______________________

nonexistent olfactory sensations

EXPERIENCES
Has the child experienced any of the following:
Traumatic medical procedures

Physical abuse

Emotional abuse

Sexual abuse

Witness to abuse

Traumatic medical events

Other: ________________________

Witness to suicide

NAME OF PERSON COMPLETING THIS FORM (PLEASE PRINT)

DATE:

_________________________________________________________

__________________

SIGNATURE
_________________________________________________________

Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144
Atlantachildtherapy.org 678.903.5506