Cecil Reynolds PhD + Randy W. Kamphaus, PAO Completion Format ClQuestionnaire Clinterview Structured History se BASC3 pC cL Interviewer'sClinician’s Name Date (Cras erp ee Gonder I Mate Claris) Address - Phone. — Birth Date Schoo! Age, Teacher Grade. ‘Whats this chlé’s primary language? this reera related to any type of legal orcourt proceeding? No. Yes ‘Whats this child's secondary language? DIRECTIONS: To the best ofyour abit, please answer all ofthe questions, even If some do not seem to apply. Ifyou do not understand an item, please ask the person who gave you this form to help you. PERSON ANSWERING QUESTIONS Name. Relationship to This Child Address _ Home Phone__ Work Phone. CellPhone. REFERRAL INFORMATION Why are you seeking help for this child? NOTES Who referred you to our service? PEARSON Copyright © 2015 NCS Pearson, inc. All rights reserved, Portions of this wore were previously publishes, s7eswi112 coe @PsychCorp Product Number 20826‘What kind of services are you seeking for this child (for example, change of schoo! placement, therapy, psychological testing, custody evaluation ete? PARENTS Mother's Name Stepmother? No Yes Address. Age Home Phone. Work Phone _ Cell Phone. ‘Occupation Employer How long with present employer? Highest Grade Completed. Primary Language Secondary Language Father's Name, Stepfather? No Yes Address. Age Home Phone. Work Phone _ ___ Cell Phone, Occupation _ Employer How long with present employer? Primary Language Does this child have other paren(sVstepparentsi? No if yes, please provide the following information. Name. Relationship to Tis Child — ares Highest Grade Completed Secondary Language. Yes Age Phone Home Cell Work Sec One Name Relationship to This Child Address PRIMARY CAREGIVERS ee ge Home Cell Work Str One Phone PRIMARY CAREGIVERS lease et ll acluts Buin with this che) sustenance ees eters ee How long in current living situation? Please provide the following information about primary caregivers ifnot given previously. Name. Relationship t Child Address. eee ce Home Phone Work Phone. CellPhone ‘Occupation Employer How long with present employer? Highest Grade Completed Primary Language secondary Language. NOTESName. Relationship to Child Address SO age Home Phone_____WorkPhone_____ Cell Phone. ‘Occupation Employer How long with present employer? __ Highest Grade Completed Primary Language Secondary Language. CHILD CARE Ifprimary caregivers work outside the home, please provide the following information. Who cares for this child when caregivers are gone?, How many hours per day is this child in a child-care setting? How many diferent people care for this child? (Please explain) FAMILY HISTORY Isthischldclosertoone parent than the other? No. Yes_fyes, which? Has this child ever experienced any parental separations, divorces, or death? NoYes ifyes, when? How old was this child at the time? Please describe the cheumstances. ssan ericcs Shi If parents are separated or divorced: ‘Who has custody ofthis child? How often does the other parent see this child? (check one) (1 Weekly or More Often [_] Once orTwiceaMonth |] FewTimesa Year [| Never BROTHERS/SISTERS Please list all brothers and sisters, and any other children living with the family. Age Gender Relationship to This Child Living at home? How does this child get along with brother(s) andor sisters)? CHILD'S RESIDENCE (check one) J apartment (J single Home [| other CJ How long at current address? NOTESFAMILY RELATIONS Check the activities in which ths child often participates with the family. O Movies 1 Meats [conversations Visits with Relatives Church UI Games O spons Oo thips (Television other Language Spoken in the Home __ How frequently does this child see grandparents? (check one) C1 Weekly or More Often (1 Once or Twice a Month (1 Few Times a Year CI Never 11 No Grandparents tiving ‘What do you enjoy most about this child? _ What do you find most dificult about raising this child? \What would you like this child to be when he/she grows up? \What level of education do you hope this child wil complete? (check one) Di High Seno! 1 Technical or Vocational Schoo! Cl college) Law, Medical, Other Advanced Studies Who is mainly in charge of discipline inthe home?__ Dol caregivers agree on discipline? Describe discipline techniques. _ PREGNANCY ‘Was this child planned pregnancy? NoYes Was the mother undera doctor's care? No Yes ‘Number of Previous Pregnancles/Miscarrages, Check any of the following complications that occurred during the pregnancy. 1 bifficulty in Conception (1 Toxemia J Abnormal Weight Gain LL Meastes 1 Excessive Vomiting —) German Measles (1 Excessive Swelling | Emotional Problems LL Vaginal Bleeding Oflu 1 Anemia (J High Blood Pressure ther (Rh incompatibility, etc). ne C1 Maternal injury: Describe. 1 Hospitalization During Pregnancy: Reason [1 xeRays During Pregnancy: What month? J medications Used During Pregnancy: What kind? 1) Alcohol Used During Pregnancy: Frequency 4 NOTESNOTES 1) cigarettes Used During Pregnancy: Frequency C1 Other Drugs Used During Pregnancy: Type Frequency Prescription No Yes No Yes No Yes BIRTH [At this chiles bith, what was the mother'sage?__ Father's age? Mother's age at birth of first child? Was his child born ina hospital? Yes No tfno,where? Length of Pregnancy: _ weeks Birth Weight: _Ibs. oz Length of Labor: hours Apgar Scofe Child's Condition a Birth Mother's Condition at Birth — Check any of the following complications that occurred during birth. C1 Forceps Used Breech Birth Cl taborinduced LI Caesarean Delivery C1 other Delivery Complications: Describe 1 Incubator: How long? - 1 Jaundliced: Bilirubin lights? No Yes yes howlong? O. Breathing Problems Right After Birth: Describe ae C1 Supplemental Oxygen No Yes Ifyes, how long? Was anesthesia used during delivery? No Yes. Ifyes, what kind? — Length of Stayin Hospital: Mother____ days Child: days DEVELOPMENT ‘Atwhat age did ths child first do the following? Please indicate year/month of age. Tu et remo en sas sit Alone ‘Show Interest n or Attraction to Sound ae ae AE can Understand Fest Words Stand Alone ____ Speak First Words Walk Alone ____Speakin Sentences: Walkup Stairs Was this child breast-fed? No Yes When weaned? Was this child bottlefed? No Yes When weaned? When was this child tollet trained? Days Nights: Did bed. wetting occur aftertollet training? No Yes fyes, until what age? Did bed-soling occur ater tolet taining? No. Yes_ifyes, until what age?,\Were there any medical reasons for bed-werting or bed-solling? No. Yes_Ifyes, please describe. Has this child experienced any of the following problems? yes, please describe, ‘walking Difficulty NoYes. Unclear Speech No Yes. Feeding Problem No Yes Underweight Problem NoYes. ‘Overweight Problem No Yes_ Coli No. Yes. Sleep Problem No Yes sn Eating Problem No. Yes ESE ae oe Dificuty Leaming toRideaBike No Yes Difficulty Leaming t Skip No Yes. Difficulty Leatning toThrow orCatch No Yes__ During this childs fist 4 years, were any special problems noted in the following areas? f yes, please describe, Eating No. Yes. Motor Skis No Yes Sleeping Too Much No Yes_ BS Lae atin NE ara Taterins CG oa NGM estiekilc poe Sleeping Toolittie No Yes_ Fellure to Tve Notes ee Separating From Parents NoYes Excessive ying NoseVesssou serine = Which hand does this child use for writing or drawing? Eating? Has this child been forced to change writing hand? No. Yes Gtherthonnptc eee a MEDICAL HISTORY Childhood Minesses/Injuries Please check the illnesses this child has had and indicate age (year/month). Cl Measles C1 Rheumatic Fever _ (1 German Measles C1 Diphtheria. _ Mumps i Meningitis C1 chicken Pox. Oi Encephalitis = U) Tuberculosis _ —— D Anemia___ C1 whooping Cough U0 scarlet Fever Cl Head injury: Describe 1 coma or Any Loss of Consciousness: Describe H Sustained High Fever: Describe __ Ci Fever Above 108 1 Broken Bones NOTESPlease describe other serious illnesses or operations: iness/Operation Age Has this child ever been on any medication for'é months or more? No. Yes It yes, when? _ What kind? Please indicate whether this child currently has any ofthe following problems. Ifyes, describe how often, Respiratory Frequent Colds Chronic Cough Asthma Hay Fever Sinus Condition Cardiovascular Shortness of Breath or Dizziness With Physical Exertion Activity Limitation Due 10 Heart Condition Heart Murmur Gastrointestinal Excessive Vomiting Frequent Diarrhea Constipation Stomach Pain Genitourinary Usination in Pants/Bed Pain While Urinating Excessive Urination Strong Odor to Urine ‘Musculoskeletal ‘Muscle Pain Clumsy Walk Poor Posture Other Muscle Problems No Yes No Yes__ oo No Yes No Yes No Yes. = es No Yes, No Yes No Yes__ — No Yes = No Yes Se No Yes __ ee No Yes No Yes NoYes No Yes No Yes No. Yes = pee When? Where? —_ eres ia No Yes a See NO ee No Yes. ifyes, describe. NOTESSkin Frequent Rashes Bruises Easily Sores Severe Acne Itchy Skin (Eezerna) Neurological Selaures/Convulsions Speech Defects ‘Accident Prone Bites Nails Sucks Thum Grinds Teeth Has Tes/Twitehes Bangs Head Rocks Back and Forth Bowel Movements inPants/Bed No ee ee & 6:8 & Es 3-84 No Yes Yes Yes Yes Yes Yes Yes. Yes, Yes. Yes. Yes. Yes. Yes. Yes. Yes. Ifyes, describe Ifyes, describe Has this child ever taken medication to increase activity? NoYes yes, when? What medication? Has this chile ever taken tranquilizing medication? No Yes yes, when? What medication? Has this child ever taken medication for ADD, ADHD, or similar problems? No Yes yes, when? Allergies Allergy to Medicine ‘Allergy to Food ther Allergies Speech Stuttering Unclear Speech (Other Speech Problems No No No No Yes Yes Yes Yes Yes Yes Date of Most Recent Speech Exam What medication? Ifyes, describe - Ifyes, describe Ifyes, describe NOTESHearing Ear Infections Hearing Problems Ear Tubes No Yes No Yes No Yes Date of Most Recent Hearing Exam Vision ‘sion Problems No Yes Wears Glasses or Contacts NoYes Date of Most Recent Vision Exam ‘Medical Care Chile's Physician How often does this child see a doctor? Isthis child currently on medication? No Yes Ifyes, indicate ype and ‘Telephone Date of Last Vist Has this child ever been physically or sexually abused? No. Yes, yes, please discuss this issue with the person who gave you this form to complete, Has tis child ever had psychological counseling or therapy? NoYes yes, counselor's name Address Telephone ‘Type of Counseling When? Has this child ever had a neurological exam? Ifyes, neurologist’s name oy Reason for Exam No Yes Date of Exam Has this child ever had a psychological or psychiatric exam? No Yes yes, doctor's name city Reason for Exam Date of Exam NOTESFAMILY HEALTH Have any family members had any of the following? Ifyes, please specify family member's relationship to this child. fchild is not living with biological parents, please include health information on biological parents, if known. cancer 1 High Blood Pressure 1 onc Hiro C1 kiney Disease (O Diabetes: |_| Migraine Headaches HeartDisease_ Mine Sclerosis Phys Hancap 7 Atcohovorug Abuse O stroke [] Behavior Disorder. 0 Taberulosis 7] Emotional Ditrbance (Cl attheimers Disease] Mental tines J] Hemophilia. (1 Intellectual Disability, 1 Huningtons chorea 1 Nervousness (1 Muscular Dystrophy, | Parkinson's Disease Ci Seizures or Epilepsy (1 Reading Problem 7 Sikle-cet Anemia 0 other teaming Disaiy Ci Tay-Sachs Disease () Speech or Language Problem 1 Tourette’ Syndrome 1 Food alesies O aien beter 1) severe Head injury cetera Palsy other: Describe Deserlne father’s present health, Debi nthe weather Has anyone in the family ever been in special education? No Yes Ityes, who? what type of class? FRIENDSHIPS Please indicate how this child relates to other children. Has Problems Relating to or Playing With Other Children No. Yes yes, describe, _ - Fights Frequently With Playmates No Yes Prefers Playing With Younger Children NoYes Has Difficulty Making Friends No Yes Prefers to Play Alone NoYes ‘Are there children in the neighborhaad with whom this child could play? No Yes ‘What role does this child take in peer group games (for example, leader, follower, ete)? 10 anaes. aPlease indicate whether any ofthis childs friends engage in any of the following behaviors. Smoke Cigarettes No Yes Chew Tobacco No Yes Inhale Toxic Substances (eg, paint) No Yes Drink Beer, Wine,orLiquor No Yes Use Drugs tlegally(e.9, marijuana, cocaine, prescription drugs prescribed to others) No. Yes RECREATION/INTERESTS ‘What activities does this child enjoy? Sports: _ Hobbes, 28 Sees ie ere ee other Has this child's interest in participating in these activites declined recently? No Yes IFyes, describe. BEHAVIOR/TEMPERAMENT Please indicate whether this child exhibits any ofthe following behaviors. Is Easily Overstimulated in Play No Yes Seems Overly Energetic in Play No Yes Has a Short Attention Span No Yes Seems impulsive No Yes Lacks Self Control No Yes Overreacts When Faced With a Problem No. Yes Seems Unhappy Most ofthe Time NoYes Seems Uncomfortable Meeting New People No Yes Withholds Affection No Yes Requires a Lot of Parental Attention No Yes Hides Feelings No Yes Cannot Calm Down No Yes Has Fears No. Yes Ifyes, describe. ‘What makes this child angry? EDUCATIONAL HISTORY Preschool and Daycare Does or did this child attend preschool/daycare? No Yes Atwhatage? ‘Amount of Time per Day Days per Week ‘Any problems in preschool? No. Yes Ifyes, describe. Does or did this child attend kindergarten? No Yes ‘Any problems in kindergarten? No Yes Ifyes, describe. Elementary/High School Please indicate whether this child has had any of the following school experiences. Has Changed Schools for Reasons Other Than Normal Academic Progression No Yes Ifyes, when and why?, NOTESNOTES Has Been Retained a Grade in School No Yes. ifyes, when and why? Has Skipped a Grade in School No Yes Ifyes, when and why? Has Difficulty With Reading No Yes Hfyes,describe, Has Difficulty With Math No Yes. Ifyes, describe. Gets Poor Grades No Yes Describe most recent report card results Has Been Tested for Special Education No Yes ifyes, when? Currently Is Placedin Special-Education Class NoYes Ifyes,what type of class? Hours per Day Dislikes Going to School No Yes Js Absent From School Frequently No Yes. fyes, why? If in high school, when wil this child graduate? Do you have any concerns about the quality of thischile's school or teachers? No. Yes Hyes, describe ADDITIONAL COMMENTS Copyright © 2015 NCS Pearson, Inc Al rights reserved, Portions of thls work were previously pubished POANRSOYNIM Warning: no part ots pulcation may be reproduced or transmitted in any form or by any means, electronic or mmashanteah ictus photocopy, recog, or any Infermason storage and rereva rate, thou the express {ertten permission of te copyrait owner fringes and reorderhg: pearson, PSL desian, PsyehCorp, and BASC are trademarks, In the US andor other counties, of Pearson Eaueation, 800.627.7271 Inc, or Its. wie i vw Pearsoncinial com PsyehCorp isan imprint of Pearson Clinical Assessment. NCS Pearson, Ine. 5601 Green Valley Drive Bloomington, MN 55437, Printed in the United States of America.