1. Name: Sex: Age: DOB
2. Natural Child Yes / No If adopted, at what ageFoster since
3. Parent’s Names (include step-parents, foster parents, etc.)
4. Comments about custody and visitation (if applicable):
5. Primary reason you are concerned about your child?
6. Parent's Email

Please List Brother and Sisters

SCHOOL HISTORY

1. Present School: Grade: Teacher:
2. Has child ever repeated any grade?
3. Is child in special education services? No Yes, what kind?
4. Please describe academic or other problems your child has had in school

PREGNANCY, MEDICAL PROVIDERS AND DEVELOPMENTAL HISTORY

1. Pregnancy

Mother used during pregnancy: alcoholdrugscigarettes
Delivery: NormalBreechCesareanTransectionalFull-termPrematureif premature, number of weeks
Problems at birth: (for example: infant given oxygen, blood transfusion, placed in an Incubator, etc.)

2. Medical Providers

Name, Address, Phone Number and Fax of Psychiatrist/Neurologist:

Name, Address, Phone Number and Fax of Primary Care Physician (PCP):

3. Developmental History

State approximate age when child did the following:

Walked alone

Patient/Guardian/ Statement: “I agree that the above information is true to the best of my knowledge. And, I give permission for the treating Psychologist to collaborate with all medical providers listed in this document as it relates to my (or my child’s) continuing mental health and/or medical care. I can modify /revoke this decision at anytime if I submit a request in writing.”

Patient/Guardian Name Printed/Date
Patient/Guardian Signature/Date