General Information

Father’s Name…………………………………
Child’s Name…………………………
Age……………………………… Age……………………..

Occupation………………………………………
Mother’s name……………………….
……..
Age………………………….
Occupation……………………………
Parents are currently:-
…….
☐Married ☐Divorced ☐Remarried ☐Never
married ☐Other:

If separated or divorced, how old was the child when the separation occurred?

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If remarried, how old was the child when stepparent entered the family?

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Child's legal custodian/guardian is: ……………………………………………………………………………………..

Are there other relatives or adults that are important caretakers for your child (i.e. stepparent,
significant other, grandparent)? Please list:

Name Age Relationship

Please list information about your child’s brother or sisters below (please include stepsiblings):

Name Age Any physical or psychological diagnosis

Please list all people living in the household.

Name Sex Relationship to child Age

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Dominant language spoken in home

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Presenting problem
Briefly describe child’s current difficulties

How long has this problem been of concern to you?

When was the problem first noticed?

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What seems to help the problem?

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What seems to worse the problem?

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Have you noticed changes in child’s behaviour? If yes, please describe.

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Has the child received evaluation or treatment for current problem or similar problems? If
yes, when and with whom?

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Social and behaviour checklist

O has difficulty with hearing O has poor bowel control

O eats poorly
O is overreactive
O has difficulty with vision
O is fidgety
O has trouble sleeping
O is disorganized
O has difficulty in making friends
O is unusually talkative
O has difficulty in keeping friends
O is forgetful
O refuses to share
O daydreams frequently
O prefers to be alone
O is impulsive
O does not get along well with
O has many accidents
brothers/sisters
O feels that he or she is bad
O does not get along with adults
O moves slowly
O fights verbally with adults
O has poor attention span
O fight physically with adults
O has poor memory
O is aggressive
O talks about wanting to die
O is shy or timid
O has difficulty accepting criticism
O clings to others
O tires easily, has little energy
O breaks objects deliberately
O is more interested in things (objects)
O has low self-esteem
than people.
O has frequent crying spells
O engages in behaviour that could
be dangerous to self or others.
Educational history

O has difficulty reading O has difficulty paying attention in class

O has difficulty with arithmetic
O has difficulty with spelling
O has difficulty with handwriting
O has difficulty in paying attention in class
O has difficulty with other subjects
…………………………………………….
O forgets homework
O has difficulty remembering things
O has difficulty getting started on his or her
homework
O has difficulty understanding homework
directions
O has difficulty sitting still in class
O has difficulty waiting turn in school
O has difficulty taking notes in class
O has difficulty responding others’ rights
O makes careless mistakes
O has difficulty keeping notebook
organized
O has difficulty finishing a project on time
O has difficulty getting along with teaches
O has difficulty getting along with other
children

O has difficulty getting on his or her own O dislike school

homework O resists going to school
O has difficulty asking for help when it is
needed
O has difficulty remembering to hand in
homework
O refuses to do homework
Health

List all childhood illnesses, chronic ear infections, hospitalizations, medications, allergies, head
trauma, important accidents and injuries, surgeries, periods of loss of consciousness,
convulsions/seizures, and other medical conditions:

Condition Age Treated by whom? Consequences?

Please list family members’ medical history. Any illness or condition that any member of the family
has had.

Please list all current medications the child is taking:

Medication……………………………………………………………

Dosage…………………………………………………………….

Evaluation/Intervention

Is there anyone in the child's family that has ever had: Family member(s):

O Learning Difficulties ………………………………………………………………….

O Attentional Problems …………………………………………………………………. O Emotional Difficulties

………………………………………………………………… O Diagnosed Disorder(s)

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O Alcohol or Drug problems …………………………………………………………………

Any previous diagnoses for your child?

O Yes O No

If Yes, please describe

Diagnosis Age testing completed

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Please list any current intervention your child is receiving (Speech, OT, PT, psychotherapy):

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Please list any past treatment for your child (Speech, OT, PT, psychotherapy):

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Assessments
Any previous assessments administered on your child. Please mention with the year of
administration.

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Please send assessment copies to psych100z@outlook.com

Other information
What are the child’s favourite activities?

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What activities does the child likes least?

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What chores child do around the house?

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What are the child’s assets or strength?

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Is there any other information that you may think will help us in working with the child?

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