PARENT HISTORY SHEET

Today's Date:

Email Address:

Mother

Mother's Name:

Martial Status:

Home Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Email:

Employer:

Employer Phone:

Father

Father's Name:

Martial Status:

Home Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Employer:

Employer Phone:

Spouse if Different from Father

Name of Spouse if Different from Father:

Address if Different from above:

City:

State:

Insurance

Name of Insurance Company:

Phone:

Who is the insured:

Child

Child’s Name:

School:

Grade:

Teacher:

Family Physician:

Phone:

Current Diagnosis:

Medication: Please List:

Any Known Allergies:

Referred By:

Reason for Referral:

Substance Assessment

History of use:

Alcohol:

Drug:

Tobacco:

Current Use:

Alcohol:

Drug:

Tobacco:

Members of Household (those living with child):

Parent or Parents:

Name:

Occupation:

Name:

Occupation:

Other Adults (s):

Name:

Occupation:

Children: (Please indicate if any are step-siblings and if so, how long they have lived in the same household)

Name:

Have any siblings had behavior problems?:

Emotional Disturbance?:

School Failure?:

Significant Medical Problems?:

Parent History

Are you presently......

Married?:

How Long?:

Divorced?:

How Long?:

Separated?:

How Long?:

Are you the....

Biological Parent?:

Adoptive Parent?:

Age of Child when adopted:

Step Parent?:

Age of Child when you became parent:

Does the child relate to a parent or step-parent not living in the home?:

If yes, Who?:

Have there been any deaths in the immediate family?:

Any illness of long duration?:

Has anyone in the family been in therapy previously?:

If yes, who in the family was seen?:

When?:

Name of Therapist?:

Has anyone in the family had previous psychological testing?:

If so who?:

When?:

Name of person doing the testing?:

Development

Was the pregnancy with this child abnormal in any way?:

If yes, Please explain:

Were there any complications with the birth?:

If yes, Please explain:

Have there been (in the past) significant medical problems?:

If yes, Please explain:

At birth he/she weighed:

As a baby, he/she was:

If any others, Please explain:

At what age did your child accomplish each of the following:
Sitting up:

Walking:

Crawling:

1st word spoken:

1st sentence:

School History

Has your child received any special tutoring?:

If yes, what subjects:

Has your child been in a special class?:

If yes, please explain what class and how long:

School History

Pre-School:

Where?:

Behavior Problems:

Academic Problems:

Kindergarten:

Where?:

Behavior Problems:

Academic Problems: