Parent Completed Personal History FormóChild/Adolescent

The Family Resource Center

When completed, fax to (281) 444-0368 or email to jagvw@earthlink.net

Clientís name: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Date: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Gender: ___ FÝÝÝ ___ MÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Date of birth: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Age: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Grade in school: ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Form completed by (if someone other than client): ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Address: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝ City: ÝÝÝÝÝ State: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Zip: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Phone (home): ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ (work): ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Ext: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

If you need any more space for any of the following questions please use the back of the sheet.

Primary reason(s) for seeking services:

ÝÝÝÝ ÝAnger managementÝÝÝ ÝÝÝÝ AnxietyÝÝÝÝÝ ÝÝÝÝ CopingÝÝÝÝÝÝ ÝÝÝÝ Depression

ÝÝÝÝ ÝEating disorderÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Fear/phobiasÝÝ ÝÝÝÝ Mental confusionÝÝÝÝÝÝÝ ÝÝÝÝ Sexual concerns

ÝÝÝÝ ÝSleeping problemsÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Addictive behaviorsÝÝÝÝÝÝÝÝ ÝÝÝÝ Alcohol/drugs ÝÝÝÝÝÝÝ Hyperactivity

ÝÝÝÝ ÝOther mental health concerns (specify): ÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Family History

Parents

With whom does the child live at this time? ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Are parentís divorced or separated? ÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

If Yes, who has legal custody? ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Were the childís parents ever married? Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

Is there any significant information about the parentsí relationship or treatment toward the child which might be beneficial in counseling? ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

If Yes, describe: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Clientís Mother

Name: ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Age: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Occupation: ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝFTÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝPT

Where employed: ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Work phone: Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Motherís education: ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Is the child currently living with mother? ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

ÝÝÝÝ ÝNatural parent ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝStep-parent ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Adoptive parent ÝÝÝÝÝÝÝÝÝÝÝÝÝ Foster home Ý ÝOther (specify): ÝÝÝÝÝÝÝÝ

Is there anything notable, unusual or stressful about the childís relationship with the mother?

ÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝ ÝNoÝÝÝ If Yes, please explain: ÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

How is the child disciplined by the mother? ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

For what reasons is the child disciplined by the mother? ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Clientís Father

Name: ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Age: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Occupation: ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝFTÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝPT

Where employed: ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Work phone: Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Fatherís education: ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Is the child currently living with father? ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

ÝÝÝÝ ÝNatural parent ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝStep-parent ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Adoptive parent ÝÝÝÝÝÝÝÝÝÝÝÝÝ Foster home Ý ÝOther (specify): ÝÝÝÝÝÝÝÝ

Is there anything notable, unusual or stressful about the childís relationship with the mother?

ÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝ ÝNoÝÝÝ If Yes, please explain: ÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

How is the child disciplined by the father? ÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

For what reasons is the child disciplined by the father? ÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Clientís Siblings and Others Who Live in the Household

ÝÝÝÝÝÝÝ Quality of relationship

Names of SiblingsÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ AgeÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ GenderÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ LivesÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ with the client

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ homeÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝawayÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ homeÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝawayÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ homeÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝawayÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ homeÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝawayÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

Others living inÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Relationship

the householdÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ (e.g., cousin, foster child)

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝF ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝM ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ poorÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝaverageÝ ÝÝÝ ÝÝÝÝ Ýgood

Comments: ÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Family Health History

Have any of the following diseases occurred among the childís blood relatives? (parents, siblings, aunts, uncles or grandparents) Check those which apply:

ÝÝÝÝ ÝAllergiesÝÝÝ ÝÝÝÝ DeafnessÝÝ ÝÝÝÝ Muscular Dystrophy

ÝÝÝÝ ÝAnemiaÝÝÝÝÝ ÝÝÝÝ DiabetesÝÝÝ ÝÝÝÝ Nervousness

ÝÝÝÝ ÝAsthmaÝÝÝÝÝ ÝÝÝÝ Glandular problemsÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Perceptual motor disorder

ÝÝÝÝ ÝBleeding tendencyÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Heart diseasesÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Mental Retardation

ÝÝÝÝ ÝBlindnessÝ ÝÝÝÝ High blood pressureÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Seizures

ÝÝÝÝ ÝCancerÝÝÝÝÝÝÝ ÝÝÝÝ Kidney diseaseÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Spinal Bifida

ÝÝÝÝ ÝCerebral PalsyÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Mental illnessÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Suicide

ÝÝÝÝ ÝCleft lipsÝÝÝ ÝÝÝÝ MigrainesÝ ÝÝÝÝ Other (specify): ÝÝÝÝÝÝÝÝ

ÝÝÝÝ ÝCleft palate ÝÝÝÝÝÝÝ Multiple sclerosisÝÝÝÝÝÝÝÝÝÝ

Comments re: Family Health: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Childhood/Adolescent History

Pregnancy/Birth

Has the childís mother had any occurances of miscarriages or stillborns? ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

If Yes, describe: ÝÝÝÝÝÝÝÝ

Was the pregnancy with child planned? ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Length of pregnancy: ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Motherís age at childís birth: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Fatherís age at childís birth: ÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Child number Ý Ýof ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Ýtotal children.

How many pounds did the mother gain during the pregnancy? ÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

While pregnant did the mother smoke?ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ YesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ If Yes, what amount: ÝÝÝÝÝÝÝÝÝÝ

Did the mother use drugs of alcohol?ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ YesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ If Yes, type/amount: Ý

While pregnant, did the mother have any medical or emotional difficulties? (e.g., surgery, hypertension, medication) Ý ÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

If Yes, describe: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Length of labor: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Induced: ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Caesarean? ÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

Babyís birth weight: ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Babyís birth length: ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Describe any physical or emotional complications with the delivery: ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Describe any complications for the mother or the baby after the birth: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Length of hospitalization: Mother: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Baby: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Infancy/Toddlerhood Check all which apply:

ÝÝÝÝ ÝBreast fedÝ ÝÝÝÝ Milk allergiesÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ VomitingÝÝÝ ÝÝÝÝ Diarrhea

ÝÝÝÝ ÝBottle fedÝÝ ÝÝÝÝ RashesÝÝÝÝÝÝ ÝÝÝÝ ColicÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Constipation

ÝÝÝÝ ÝNot cuddly ÝÝÝÝÝÝÝ Cried oftenÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Rarely cried ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Overactive

ÝÝÝÝ ÝResisted solid foodÝÝÝÝÝÝÝ ÝÝÝÝ Trouble sleepingÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Irritable when awakenedÝÝÝÝÝÝÝÝ ÝÝÝÝ Lethargic

Developmental History Please note the age at which the following behaviors took place:

Sat alone: ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Dressed self: Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Took 1st steps: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Tied shoe laces: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Spoke words: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Rode two-wheeled bike: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Spoke sentences: ÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Toilet trained: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Weaned: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Dry during day: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Fed self: ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Dry during night: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Compared with others in the family, childís development was: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝslowÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝaverageÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Ýfast

Age for following developments (fill in where applicable)

Began puberty: ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Menstruation: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Voice change: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Convulsions: Ý

Breast development: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Injuries or hospitalization: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Issues that affected childís development (e.g., physical/sexual abuse, inadequate nutrition, neglect, etc.)

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Education

Current school: ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ School phone number: ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Type of school: ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝPublicÝÝ ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝPrivateÝÝ ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝHome schooledÝÝ ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝOther (specify): ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Grade: ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Teacher: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ School Counselor: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

In special education? ÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ If Yes, describe: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

In gifted program? ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ If Yes, describe: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Has child ever been held back in school? ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNoÝÝÝ If Yes, describe: ÝÝÝÝÝÝÝÝ

Which subjects does the child enjoy in school? ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Which subjects does the child dislike in school? ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

What grades does the child usually receive in school? ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Have there been any recent changes in the childís grades? ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

If Yes, describe: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Has the child been tested psychologically? ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝYesÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝNo

If Yes, describe: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Check the descriptions which specifically relate to your child.

Feelings about School Work:

ÝÝÝÝ ÝAnxiousÝÝÝÝ ÝÝÝÝ PassiveÝÝÝÝÝ ÝÝÝÝ EnthusiasticÝÝÝ ÝÝÝÝ Fearful

ÝÝÝÝ ÝEagerÝÝÝÝÝÝÝÝÝ ÝÝÝÝ No expressionÝÝÝÝÝÝ ÝÝÝÝ BoredÝÝÝÝÝÝÝÝ ÝÝÝÝ Rebellious

ÝÝÝÝ ÝOther (describe): ÝÝÝÝÝÝ

Approach to School Work:

ÝÝÝÝ ÝOrganizedÝ ÝÝÝÝ IndustriousÝÝÝÝÝ ÝÝÝÝ ResponsibleÝÝÝ ÝÝÝÝ Interested

ÝÝÝÝ ÝSelf-directedÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ No initiativeÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ RefusesÝÝÝÝÝ ÝÝÝÝ Does only what is expected

ÝÝÝÝ ÝSloppyÝÝÝÝÝÝ ÝÝÝÝ DisorganizedÝÝ ÝÝÝÝ CooperativeÝÝÝÝ ÝÝÝÝ Doesnít complete assignments

ÝÝÝÝ ÝOther (describe): ÝÝÝÝÝÝ

Performance in School (Parentís Opinion):

ÝÝÝÝ ÝSatisfactoryÝÝÝÝ ÝÝÝÝ Underachiever ÝÝÝÝÝÝÝ Overachiever

ÝÝÝÝ ÝOther (describe): ÝÝÝÝÝÝ

Childís Peer Relationships:

ÝÝÝÝ ÝSpontaneousÝÝ ÝÝÝÝ FollowerÝÝÝÝ ÝÝÝÝ LeaderÝÝÝÝÝÝÝ ÝÝÝÝ Difficulty making friends

ÝÝÝÝ ÝMakes friends easilyÝÝ ÝÝÝÝ Long-time friendsÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Shares easily

ÝÝÝÝ ÝOther (describe): ÝÝÝÝÝÝ

Who handles responsibility for your child in the following areas?

ÝÝÝÝ School:ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ MotherÝÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝFatherÝÝ ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝSharedÝÝ ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝOther (specify): ÝÝÝÝÝÝÝÝ

ÝÝÝÝ Health:ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ MotherÝÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝFatherÝÝ ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝSharedÝÝ ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝOther (specify): ÝÝÝÝÝÝÝÝ

ÝÝÝÝ Problem behavior:ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ MotherÝÝ ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝFatherÝÝ ÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝSharedÝÝ ÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ ÝOther (specify): ÝÝÝÝÝÝÝÝ

If the child is involved in a vocational program or works a job, please fill in the following:

What is the childís attitude toward work? ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝPoorÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝAverageÝÝÝ ÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝGoodÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝExcellent

Current employer: ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Position: ÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Hours per week: ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

How have the childís grades in school been affected since working? ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝLowerÝ ÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝSameÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝHigher

How many previous jobs or placements has the child had? ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Usual length of employment: ÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Usual reason for leaving: ÝÝÝÝ

Leisure/Recreational

Describe special areas of interest or hobbies (e.g., art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, exercising, diet/health, hunting, fishing, bowling, school activities, scouts, etc.)

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ActivityÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ How often now?ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ How often in the past?

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Ý ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Medical/Physical Health

ÝÝÝÝ ÝAbortionÝÝÝ ÝÝÝÝ HayfeverÝÝÝ ÝÝÝÝ Pneumonia

ÝÝÝÝ ÝAsthmaÝÝÝÝÝ ÝÝÝÝ Heart troubleÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Polio

ÝÝÝÝ ÝBlackoutsÝ ÝÝÝÝ HepatitisÝÝÝ ÝÝÝÝ Pregnancy

ÝÝÝÝ ÝBronchitisÝ ÝÝÝÝ HivesÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Rheumatic Fever

ÝÝÝÝ ÝCerebral PalsyÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ InfluenzaÝÝÝ ÝÝÝÝ Scarlet Fever

ÝÝÝÝ ÝChicken PoxÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ Lead poisoningÝÝÝÝÝÝÝ ÝÝÝÝ Seizures

ÝÝÝÝ ÝCongenital problemsÝÝÝÝÝÝÝÝÝ ÝÝÝÝ MeaslesÝÝÝÝ ÝÝÝÝ Severe colds

ÝÝÝÝ ÝCroupÝÝÝÝÝÝÝÝ ÝÝÝÝ Meningitis ÝÝÝÝ Severe head injury

ÝÝÝÝ ÝDiabetesÝÝÝ ÝÝÝÝ MiscarriageÝÝÝÝ ÝÝÝÝ Sexually transmitted disease

ÝÝÝÝ ÝDiphtheria ÝÝÝÝ Multiple sclerosisÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Thyroid disorders

ÝÝÝÝ ÝDizzinessÝÝ ÝÝÝÝ MumpsÝÝÝÝÝ ÝÝÝÝ Vision problems

ÝÝÝÝ ÝEar achesÝÝ ÝÝÝÝ Muscular DystrophyÝÝÝÝÝÝ ÝÝÝÝ Wearing glasses

ÝÝÝÝ ÝEar infectionsÝÝÝÝÝÝÝÝ ÝÝÝÝ Nose bleedsÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Whooping cough

ÝÝÝÝ ÝEczemaÝÝÝÝÝÝ ÝÝÝÝ Other skin rashesÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝ Other

ÝÝÝÝ ÝEncephalitisÝÝÝÝ ÝÝÝÝ ParalysisÝÝÝ

ÝÝÝÝ ÝFeversÝÝÝÝÝÝÝ ÝÝÝÝ Pleurisy

List any current health concerns: ÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

List any recent health or physical changes: ÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

Nutrition

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ

ÝÝÝ MealÝÝÝ How oftenÝÝÝ Typical foods eatenÝÝÝ Typical amount eaten

ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ (times per week)

BreakfastÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ / weekÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ NoÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝLowÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝMedÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝÝ ÝHigh

LunchÝÝÝÝÝÝÝÝÝÝÝÝÝÝ