Please complete this document when instructed for a psychological evaluation. CATALPA BEHAVIORAL FAMILY HISTORY FORM "*" indicates required fields Step 1 of 2 50% Form completed by:* In the event that there is an error with form submission, we will need to contact you directly. Please provide the best phone number to reach you if follow up is needed. Contact Number:*Client’s legal first name:* Client’s legal last name:* Client’s preferred name: Client’s date of birth:* Client's primary language: Parent's primary language: FAMILY INFORMATIONParent Name #1:* Relationship to client*Select this parent's relationship to the clientMotherFatherStepparentLegal GuardianFoster ParentOtherAge: Education: Parent Name #2: Relationship to client:Select this parent's relationship to the clientMotherFatherStepparentLegal GuardianFoster ParentOtherSpecify relationship to the client: Age: Education: Parent's marital status:Make SelectionMarriedSeparatedDivorcedNever MarriedDeceasedStep parents: Was the client adopted?Make Selectionmake selectionNoYesIf yes, client's age: Other household (family) members:Custody:Visitation Schedule:Guardian ad litem: Primary Care Provider: Referral Source: Other treating medical or mental health providers (list name and clinic):Current mental health diagnoses: Past mental health diagnoses: Current medications (dosages): Past medications: Reason for referral: What would you (as a parent) like to see happen as a result of your child's evaluation?Please select your child's top 5 strengths: Humor Creativity Loving Kind Active Forgiving Fair A Leader Brave Curious Hopeful Love of Learning Social Other (please list below) Other (please specify) Current Behavioral Concerns (check all that apply): Can’t sit still Argumentative Defiant Temper Outbursts Delinquency Rule Violations Impulsivity Eating Problems Sleep Problems Compulsive Behavior Alcohol Usage Drug Usage School Refusal Academic Difficulties Aggression Lies Current Emotional Concerns (check all that apply): Nervousness Panic Episodes Phobias Depression Greif Mood Instability Anger Rage Irritability Low Self Esteem Hypersensitivity Current Interpersonal Concerns (check all that apply): Conflicts w/Adults Conflicts w/Siblings Conflicts w/Peers Lack of Friends Poor Social Skills Inappropriate Social Behavior Fighting Cruelty to Others Negative Peer Group Current Cognitive Concerns (check all that apply): Poor Concentration Distractibility Disorganization Memory Difficulties Learning Problems Language Problems Obsessive Thoughts Racing Thoughts LEGAL PROBLEMSCurrent Legal Problems: Past Legal Problems: County social worker/parole officer's name: PREGNANCY AND BIRTH HISTORYAge of mother at time of child's delivery: Age of father at time of child's delivery: # of prior pregnancies: # of prior miscarriages: Fertility procedures: Health problems during pregnancy (select all that apply): Vaginal Bleeding Toxemia Hypertension Gestational Diabetes Blood Incompatibility Fever/rash (e.g., flu, measles) Trauma Antibiotics Alcohol Smoking Illicit drugs (please list below) Medications (please list below) Other (please list below) Illicit drugs: Medications: Other: EDUCATIONAL HISTORYCurrent School: Current grade level: Education:Make SelectionRegular EducationSpecial EducationType of IEPMake SelectionLDEBDID/CDS/LOHIAutismTBIAny grades skipped/repeated? Teacher reports problems in (please check all that apply): Reading Spellinig Math Written Language Organization Penmanship Attention Behavior Social Adjustment Work Completion Past history of academic/behavior difficulties reported by teachs in (please check all that apply): Preschool Elementary School Middle School High School Concerns: MEDICAL HISTORYHas vision been checked?Make SelectionYesNoAny problems? Has hearing been checked?Make SelectionYesNoAny problems? CT/MRI? If so, date(s): Results: EEG? If so, date(s): Results: List serious illnesses/injuries/surgeries/hospitalizations/impatient treatment programs:Does your child have a history of (select all that apply): Physical/sexual abuse Failure to thrive Febrile seizures Epilepsy Lead poisoning Asthma/allergies Headaches Migraines Loss of consciousness Frequent ear infections Ear tubes Tics/twitching Repetitive/stereotypic movements Cancer Neglect Self injurious behaviors Staring spells Meningitis/encephalitis Diabetes Abdominal pain/vomiting Sleep difficulties Eating problems Clumsiness Dizziness Drug allergies Thyroid problems Kidney problems Hypertension Describe head injuries (e.g., date, reason, loss of consciousness, changes in cognition/behavior): Delivery was: Make Selection Vaginal Cesarean Reason for Cesarean: Baby was: Make Selection Full term Premature If premature, how many weeks at gestation: Apgar Scores (if known): Birth weight: ICU days: Days in hospital: Birth Complications (please check all that apply) Cord around neck Meconium staining Aspiration Lacking oxygen Janudice Prolonged labor Medical problems after discharge:Post partum depression: DEVELOPMENT HISTORYAge sat alone: Age crawled: Age stood: Age walked: Fine Motor Delays (e.g., cutting, coloring, letter formation): Gross Motor Delays (e.g., running, skipping, biking, playing ball): HandednessMake SelectionRightLeftBothFamily history of left handedness:Make SelectionYesNoOccupational Therapy (ages): Physical Therapy (ages): Age spoke first word: Age put 2-3 words together: Speech delays/problems (e.g., articulation, stuttering): Oral motor problems (e.g., late drooling, poor sucking): Speech/Language Therapy(ages): Slow to learn alphabet?Make SelectionYesNoSlow to name colors?Make SelectionYesNoSlow to count?Make SelectionYesNoAge toilet trained – urine: Age toilet trained – bowel: Problems with daytime wetting?Make SelectionYesNoProblems with nighttime wetting?Make SelectionYesNoProblems with soiling?Make SelectionYesNoCurrent toileting problems: Does your child (please select all that apply): Get along with other children Get along with other adults Have friends Keep friends Understand gestures Understand social cues Have a good sense of humor Participate in group activities Have problems w/peer pressure Does your child/adolescent use the following substances (please select all that apply): Caffeine Nicotine Alcohol Marijuana Other drugs How much and how often does your child/adolescent use the above substances? Has your child/adolescent ever been treated for AODA problems? FAMILY HISTORY Please check all that applySuicide attempt(s) Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Completed suicide Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Depression Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Bipolar disorder Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Anxiety Disorder Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Panic disorder Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other OCD Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Schizophrenia Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other ADHD Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Autism/Aspergers Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Learning problems Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Alcoholism Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Other drug abuse Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Seizures/Epilepsy Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Thyroid problems Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Diabetes Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Cancer Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Hypertension Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Other neurological Biological Mother Biological Father Sibling Paternal Grandparent Maternal Grandparents Other Has your child been given any previous mental health diagnoses?Make SelectionYesNoUncertainExplain:Has your child been to counseling in the past?Make SelectionNoYesDates: Has your child been hospitalized for psychiatric reasons?Make SelectionNoYesDates & hospital: HEALTH HISTORY Please indicate below if any of the following apply to: Client, Mother, Father, Sibling, Grandparent, or OtherHiddenHIPAA Forms Plugin Email Δ