Biographical Information - Child

 

 

Referred by:______________________________________Date:________________________________

Please answer all questions as specifically and completely as possible.  Thank you.

 

Childs Name:__________________________________________     Child’s SS#:  ________ /______ / _____________

 

Date of Birth:____/____/____                Current Age: ________________              Gender:   M         F

 

School Grade:________________School:___________________________________________________________________

 

Home Address:______________________________________Apt#_______City______________________Zip___________

 

Home Phone: (          )________________________          Cell Phone: (            ) _____________________________________

 

Siblings (names, ages, gender)_____________________________________________________________________________

 

_____________________________________________________________________________________________________

 

Please indicate with whom the child lives (circle appropriate responses):

 

Biological Father                      Biological Mother                      Step/Other Father                       Step/Other Mother

     Other (please describe) _______________________________________________________________________________

Biological Father's Name:___________________________ Date of Birth____/____/____  SS#: _______________________

Home Phone (       )__________________  Cell (          ) ____________________email: ______________________________

Employer___________________________ Job title _____________________ Work Phone (      )______________________

Military Service: Branch of Service ________________Deployed ___________________Dates Served__________________

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Biological Mother's Name: __________________________Date of Birth____/____/____ SS#: _______________________   

Home Phone (       )__________________  Cell (          ) ____________________email: ______________________________

Employer___________________________  Job title _____________________  Work Phone (      )_____________________

Military Service: Branch of Service ________________Deployed ___________________Dates Served__________________

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Step/Other Father's Name _____________________Date of Birth____/____/____ SS#: _____________________________

 Home Phone (       )__________________  Cell (          ) ____________________email: ______________________________

Employer___________________________  Job title _____________________  Work Phone (      )_____________________

Military Service: Branch of Service ________________Deployed ___________________Dates Served__________________

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Step/Other Mother's Name:___________________Date of Birth____/____/____ SS#: ______________________________

Home Phone (       )__________________  Cell (          ) ____________________email: ______________________________

Employer___________________________  Job title _____________________  Work Phone (      )_____________________

Military Service: Branch of Service ________________Deployed ___________________Dates Served__________________

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Developmental History:

 

Describe any complications experienced during the pregnancy or at the time of birth: ________________________________

 

_____________________________________________________________________________________________________

 

Approximate weight at birth: ______lbs ______oz. Was delivery normal____ or Cesarean Section______________________

 

Approximate ages of the following:  Age sat up______ Age walked ______ Age stopped breast or bottle feeding __________

 

                  Age first word_______ Age talked in sentences ______ Age toilet trained___________

 

 

Please circle any of the following that may apply to your child:

 

Easily distracted                                                        Bullies others                         Cries Unnecessarily

Eats too much                                                            Defiant                                   Shy

Eats too little                                                              Disrespectful                          Too quiet

Misbehaves at home                                                  Drug use                                 Too noisy

Misbehaves at school                                     Steals                                      Too hyperactive

Underachieving at school                                         Loses temper easily               Too aggressive

Poor relations with siblings                                      Sulks                                       Sleeps too little

Poor relations with same-gender friends                Lazy                                        Sleeps too much

Poor relations with opposite-gender friends           Lies                                         Has nightmares         

Easily manipulated by friends                                 Messy                                      Has flashbacks          

Has been emotionally abused                                   Involved with gangs              Daydreams

Has been physically abused                                      Sexually promiscuous           Seems preoccupied   

Has been sexually abused                                         Has been arrested                                                                                                                             

Serious injuries, illnesses or surgeries (type and age occurred) ________________________________________________

 

Current Medications or OTC drugs: ______________________________________________________________________

 

Any allergies? ____________ If so, what type? _______________________________________________________________

 

Present Health: _______________________________________________________________________________________

 

Please list child's major interests and hobbies: ________________________________________________________________

 

Child's feelings about school: _____________________________________________________________________________

 

How is child disciplined and by whom? ____________________________________________________________________

 

Has child had previous psychotherapy?   YES  NO   If yes when? ________________________________________________

 

            with whom? _________________________ for what issues? _____________________________________________

 

Please describe reasons for seeking therapy at this time ________________________________________________________

 

_____________________________________________________________________________________________________