Mental Health History. Previous treatment, including providers, therapeutic modality (e.g., medications, psychosocial treatments) and response, and inpatient admissions. If possible, include information from other sources of clinical data, such as previous mental health records, and relevant psychological testing or consultation reports;
Mental Health History. PLEASE DO NOT LEAVE OUT ANY INFORMATION REGARDING PAST SERVICES. IF YOU ARE NOT SURE, INCLUDE THE INFORMATION SO THE PROVIDER CAN DETERMINE IF THE SERVICES MAY BE RELEVANT. INCLUDE ALL INFORMATION FROM THROUGHOUT YOUR LIFETIME. IF YOU NEED ADDITIONAL SPACE, PLEASE INCLUDE INFORMATION ON A SEPARATE PAGE. TESTING
Mental Health History. Has your child had previous psychotherapy services or counseling in the past? Yes No If Yes: Name of Provider: Dates? Name of Provider: Dates? Is your child seeing a psychiatrist for medication? Yes No Name of Psychiatrist: Dates: Medication the Psychiatrist Prescribed: Is there any history of self-harm or suicidal thoughts, threats, or attempts? Please Explain: List any previous or current mental health diagnoses: Psychosocial Functioning Describe the child’s personality: What are your child’s non-academic strengths? What are your child’s non-academic weaknesses? How does the child spend his/her free time? In what community or extracurricular activities is your child involved? Any concerns about child’s social group/friends? Explain: Any concerns about substance use? Explain: Please place a mark next to behaviors that you believe your child exhibits to an excessive or exaggerated degree when compared to other children his or her age. Sleeping and Eating ❑ Nightmares ❑ Trouble falling asleep ❑ Trouble staying asleep in the morning ❑ Decreased need for sleep without getting tired ❑ Excessive snoring during sleep ❑ Eats Poorly ❑ Eats excessively Social Development ❑ Prefers to be alone ❑ Excessively shy or timid ❑ More interested in objects than people view ❑ Difficulty making friends ❑ Teased by other children ❑ Bullies other children ❑ Excessive daydreaming and fantasy life Motor Skills ❑ Poor fine motor coordination ❑ Poor gross motor coordination ❑ Generally “clumsy Other Problems ❑ Bladder control problems ❑ Poor bowel control (soils self) ❑ Any history of motor/vocal tics ❑ Overreacts to noises ❑ Overreacts to touch ❑ Problems with taste or smell Behavior ❑ Stubborn ❑ Irritable, angry, or resentful ❑ Frequent tantrums ❑ Strikes out at others ❑ Throws or destroys things ❑ Lying ❑ Stealing ❑ Argues with Adults ❑ Low frustration threshold ❑ Daredevil behavior ❑ Runs away ❑ Needs a lot of supervision ❑ Doesn’t empathize with others ❑ Overly trusting of others ❑ Doesn’t appreciate humor ❑ Impulsive (does things without thinking) ❑ Poor sense of danger ❑ Skips school ❑ Seems depressed ❑ Cries frequently ❑ Excessively worried and anxious ❑ Overly preoccupied with details ❑ Overly attached to certain objects ❑ Not affected by negative consequences ❑ Drug use ❑ Alcohol use ❑ Sexual activity, behavior, or sexual talk ❑ Not sought out for friendship by peers ❑ Difficulty seeing another person’s point of view Family History
Mental Health History. 1. Please describe any behaviors that are particularly concerning to you or others:
Mental Health History. 1. Please describe any psychological or psychiatric conditions that you have previously experienced or been diagnosed with during the last 15 years, besides those allegedly attributable to ethylene oxide exposure in Part II above. For each condition listed, please indicate the date of onset and diagnosis.
