"Children/Adolescentes Biopsychosocial Assessment Form - Agape Family Counseling"

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CHILDREN / ADOLESCENETS (Age 17 and under)
SOCIAL / MEDICAL HISTORY
BIOPSYCHOSOCIAL ASSESSMENT
Please answer all questions, do not write in boxes labeled psychologist use only. Thank you.
Child’s Name: __________________________________________
Date: ____________________
Child’s age: ________ Date of Birth: ____ / ____ / ______ Sex (circle one):
Male
Female
Address: _____________________________________________________________________________
Street
_______________________________________
_________________
___________________
City
State
Zip
Phone: (Home) _________________________________ (Cell) _________________________________
Person filling out form: ___________________________________________________________________
Name of person responsible for bill: ________________________________________________________
Emergency Contact: _____________________ Relationship ________________ Phone ______________
Parents / Stepparents
Mother’s name: _______________________ Age: _____ Education: _________ Occupation: _______________________
Father’s name: ________________________ Age: _____ Education: _________ Occupation: ______________________
Stepparent’s name: ____________________ Age: ______ Education: ________ Occupation: ______________________
Stepparent’s name: ____________________ Age: ______ Education: ________ Occupation: ______________________
Marital status of parents: ____________________ If parents are separated/divorced, how old was child at time of
separation? ___________________
With whom does the child live? ___________________________________________________________
Custody:  Lives in one home with both legal parents.  Mother has physical custody.
 Father has physical custody.
 Physical custody is shared.
 Other: ___________
List all people living in household:
Name
Age
Relationship to child
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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CHILDREN / ADOLESCENETS (Age 17 and under)
SOCIAL / MEDICAL HISTORY
BIOPSYCHOSOCIAL ASSESSMENT
Please answer all questions, do not write in boxes labeled psychologist use only. Thank you.
Child’s Name: __________________________________________
Date: ____________________
Child’s age: ________ Date of Birth: ____ / ____ / ______ Sex (circle one):
Male
Female
Address: _____________________________________________________________________________
Street
_______________________________________
_________________
___________________
City
State
Zip
Phone: (Home) _________________________________ (Cell) _________________________________
Person filling out form: ___________________________________________________________________
Name of person responsible for bill: ________________________________________________________
Emergency Contact: _____________________ Relationship ________________ Phone ______________
Parents / Stepparents
Mother’s name: _______________________ Age: _____ Education: _________ Occupation: _______________________
Father’s name: ________________________ Age: _____ Education: _________ Occupation: ______________________
Stepparent’s name: ____________________ Age: ______ Education: ________ Occupation: ______________________
Stepparent’s name: ____________________ Age: ______ Education: ________ Occupation: ______________________
Marital status of parents: ____________________ If parents are separated/divorced, how old was child at time of
separation? ___________________
With whom does the child live? ___________________________________________________________
Custody:  Lives in one home with both legal parents.  Mother has physical custody.
 Father has physical custody.
 Physical custody is shared.
 Other: ___________
List all people living in household:
Name
Age
Relationship to child
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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If any brothers or sisters are living outside the home, list their names and ages:
_____________________________________________________________________________________
_____________________________________________________________________________________
If any brothers / sisters are deceased, please give name and year: _______________________________
FAMILY INFORMATION:
Place of birth: ___________________________
Child’s Race:
 African-American  Caucasian  Native American  Hispanic  Asian  Latino  Other
(specify) _____________________________________
Was the child adopted?  Yes  No If yes, at what age? _______ From where? __________________
Has the child ever been placed outside of the home?  Yes  No If yes, where? __________________
In how many residences has the child lived since birth? ________________________________________
Has the child been physically or sexually abused, assaulted or molested?  Yes  No  Don’t know
If yes, specify by whom and when: _________________________________________________________
Have the child’s parents or any other family members had any mental health or emotional problems?
 Yes  No If yes, describe: ________________________________________________________________
PRESENTING PROBLEM:
Briefly describe your child’s current difficulties: _______________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
How long has this problem been of concern to you? ___________________________________________
When was the problem first noticed? _______________________________________________________
What seems to help the problem? _________________________________________________________
What seems to make the problem worse? ___________________________________________________
Has the child received evaluation or treatment for the current problem or similar problems? Yes ___ No ___
If yes, when and with whom? _____________________________________________________________
Is the child on any medication at this time? Yes ____ No ____
If yes, please note kind of medication: ______________________________________________________
How do you want your child’s situation to be different after coming here? ___________________________
_____________________________________________________________________________________
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For Psychologist Use Only
Presenting Problem / History of Problem:
Symptoms:
Interview / Observation of child:
SOCIAL AND BEHAVIOR CHECKLIST
Place a check next to any behavior or problem that your child currently exhibits.
____ Has difficulty with speech
____ Has frequent tantrums
____ Has difficulty with hearing
____ Has frequent nightmares
____ Has difficulty with language
____ Has trouble sleeping (describe) _______________
____ Has difficulty with vision
____ Has blank staring spells
____ Has difficulty with coordination
____ Rocks back and forth
____ Prefers to be alone
____ Bangs head
____ Does not get along well with other children
____ Holds breath
____ Is aggressive
____ Eats poorly
____ Is shy or timid
____ Is stubborn
____ Has poor bowel control (soils self)
____ Is much too active
____ Is more interested in things (objects) than in people
____ Engages in behavior that could be dangerous to self (describe) ______________________________
Describe child’s relationship with his / her:
Father _______________________________________________________________________________
Mother _______________________________________________________________________________
Sibling(s)______________________________________________________________________________
Step parent(s) _________________________________________________________________________
OTHER INTERPERSONAL RELATIONSHIPS:
How do you describe the child’s friendships:
 No Friends  Only Acquaintances  Both acquaintances and close friends
How many close friends? __________
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Place a check next to any behavior or problem that your child currently exhibits.
Check
Check
______ Has special fears, habits, or mannerisms
______ Is impulsive
(describe) ________________________
______ Show daredevil behavior
______ Sucks thumb
______ Gives up easily
______ Is slow to learn
______ Wets bed
______ Other (describe): _________________
_______________________________________
_______________________________________
EDUCATIONAL HISTORY
School: ______________________________________________
Grade: __________________
Place a check next to any educational problem that your child currently exhibits:
Check
Check
______ Has difficulty with reading
______ Has difficulty with other subjects (please
______ Has difficulty with arithmetic
list) ____________________________________
______ Has difficulty with spelling
_______________________________________
______ Has difficulty with writing
______ Does not like school
Is your child in a special education class? Yes ______
No ______
If yes, what type of class? _______________________________________________________________
Has your child been held back in a grade? Yes ______
No ______
If yes, what grade and why? ______________________________________________________________
Has your child ever received special tutoring or therapy in school? Yes ______
No ______
If yes, please describe: __________________________________________________________________
Has your child ever been suspended or expelled? Yes ______
No ______
If yes, please describe: __________________________________________________________________
DEVELOPMENTAL HISTORY
During pregnancy, was mother on medication? Yes ____
No ____ If yes, what kind? ______________
During pregnancy, did mother smoke? Yes ____ No ____ If yes, how many cigarettes each day? ____
During pregnancy, did mother drink alcoholic beverages? Yes ____ No ____ If yes, what did she drink?
_______________________________________________________________________________
Approximately how much alcohol was consumed each day? _____________________________________
During pregnancy, did mother use drugs? Yes ____ No ____ If yes, what kind? __________________
Were forceps used during delivery? Yes ____ No ____
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Was a Cesarean section performed? Yes ____ No ____ If yes, for what reason? __________________
Was the child premature? Yes ____ No ____ If so, by how many months? _______________________
What was the child’s birth weight? _________________________________________________________
Were there any birth defects or complications? Yes ____ No ____ If yes, please describe: _________
_____________________________________________________________________________________
Were there any feeding problems? Yes ____ No ____ If yes, please describe: ___________________
_____________________________________________________________________________________
Were there any sleeping problems? Yes ____ No ____ If yes, please describe: ___________________
_____________________________________________________________________________________
As an infant, was the child quiet? Yes ____ No ____
As an infant, did the child like to be held? Yes ____ No ____
Were there any special problems in the growth and development of the child during the first few years?
Yes ____ No ____ If yes, please describe: ________________________________________________
The following is a list of infant and preschool behaviors. Please indicate the age at which your child first demonstrated each
behavior. If you are not certain of the age but have some idea, write the age followed by a question mark. If you don’t
remember the age at which the behavior occurred, please write a question mark.
Behavior
Age
Behavior
Age
Showed response to parent
______
Put several words together
______
Rolled over
______
Dressed self
______
Sat alone
______
Became toilet trained
______
Crawled
______
Stayed dry at night
______
Walked alone
______
Fed self
______
Babbled
______
Rode tricycle
______
Spoke first word
______
CURRENT HEALTH INFORMATION:
Describe child’s health generally:  Good  Fair  Poor Is the child sexually active?  No  Yes
List any health problems the child has had:___________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
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