Psychological Testing Family History Form

CATALPA BEHAVIORAL FAMILY HISTORY FORM

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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 INFORMATION

Parent Name #1:*

Relationship to client*

Age:

Education:

Parent Name #2:

Relationship to client:

Specify relationship to the client:

Age:

Education:

Parent's marital status:

Step parents:

Was the client adopted?

If 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:

Other (please specify)

Current Behavioral Concerns (check all that apply):

Current Emotional Concerns (check all that apply):

Current Interpersonal Concerns (check all that apply):

Current Cognitive Concerns (check all that apply):

LEGAL PROBLEMS

Current Legal Problems:

Past Legal Problems:

County social worker/parole officer's name:

PREGNANCY AND BIRTH HISTORY

Age 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):

Illicit drugs:

Medications:

Other:

EDUCATIONAL HISTORY

Current School:

Current grade level:

Education:

Type of IEP

Any grades skipped/repeated?

Teacher reports problems in (please check all that apply):

Past history of academic/behavior difficulties reported by teachs in (please check all that apply):

Preschool

Elementary School

Middle School

High School

Concerns:

MEDICAL HISTORY

Has vision been checked?

Any problems?

Has hearing been checked?

Any 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):

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)

Medical problems after discharge:

Post partum depression:

DEVELOPMENT HISTORY

Age 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):

Handedness

Family history of left handedness:

Occupational 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?

Slow to name colors?

Slow to count?

Age toilet trained – urine:

Age toilet trained – bowel:

Problems with daytime wetting?

Problems with nighttime wetting?

Problems with soiling?

Current toileting problems:

Does your child (please select all that apply):

Does your child/adolescent use the following substances (please select all that apply):

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 apply

Suicide attempt(s)

Completed suicide

Depression

Bipolar disorder

Anxiety Disorder

Panic disorder

OCD

Schizophrenia

ADHD

Autism/Aspergers

Learning problems

Alcoholism

Other drug abuse

Seizures/Epilepsy

Thyroid problems

Diabetes

Cancer

Hypertension

Other neurological

Has your child been given any previous mental health diagnoses?

Explain:

Has your child been to counseling in the past?

Dates:

Has your child been hospitalized for psychiatric reasons?

Dates & hospital:

Catalpa Health

CATALPA BEHAVIORAL FAMILY HISTORY FORM

FAMILY INFORMATION

LEGAL PROBLEMS

PREGNANCY AND BIRTH HISTORY

EDUCATIONAL HISTORY

MEDICAL HISTORY

DEVELOPMENT HISTORY

FAMILY HISTORY

HEALTH HISTORY

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