Child/Adolescent Information Sheet
Please provide the following information and answer the questions below. Please note
information you provide here is protected as confidential information.
Child’s Name:__________________________________ Today’s Date:____________________
Grade:________________School:_______________Teacher:___________________
Date of Birth:______________
Age: _________________________________ Home phone:_____________________________
Referred by (if any):
_____________________________________________________________________
Mother’s name:_________________________________
Occupation_______________________________
Home phone: ________________ Business phone:_________________
Cell phone:__________________
Father’s name:__________________________________
Occupation_______________________________
Home phone: ________________ Business phone ____________________
Cell phone:__________________
Parents: ____Married ______Separated ______Divorced
If parents are separated or divorced, how old was the child when the separation occurred?
__________________
What is the current custody
arrangement?________________________________________________________
Is the child adopted? Yes No If yes, child’s age when adopted___________________
List all people living in the household:
Name
Relationship to Child
Age
How does your child do in school academically? ______________________________________________
How does your child do in school behaviorally?_______________________________________________
Does your child have a learning or physical disability? __Y, __N, __Maybe. Specify: _________________
Does your child have an IEP Yes____
No_____
What accommodations does he/she receive:
Does your child have a mental health diagnosis? __Y, __N, Specify: _____________________________
_____________________________________________________________________________________
Does your child take medication? ___Y, ___N
If yes, who prescribes_____________
Medications (dosage and frequency)_____________________________________________
Effectiveness of Meds ___Excellent, __Good, ____Fair, ____Poor
Medical History:
Please list any birth complications (Ex: Premature, jaundice, C-section, etc.)
_____________________________________________________________________________________
Reached developmental milestones: __On time, __Early, __Late
Primary Care Physician: ____________________________ Phone:____________ Last seen on: ______
List any Medical conditions or history (Ex: Surgeries, broken bones, allergies, etc.)___________________
_____________________________________________________________________________________
Below, please specify family members (e.g., child’s sister, maternal aunt, paternal grandmother) that
have experienced any of the following:
Mother
Difficulties learning to
read
Depression
Anxiety
Bipolar
Attention difficulties
Hyperactivity
Autism
Behavior problems
Father
Sibling
Grandparent
Aunt/Uncle
Circle the symptoms your child/adolescent displays:
Anger
Anxiety
Bed wetting
Acts out sexually
Behavior problems
Defiance
Depression
Thoughts of Hurting others
Thoughts of hurting self
Drug or alcohol use
Headaches
Stomachaches
Lack of motivation
Seems tired
says negative things about self
Lying
Nightmares
Obsesses Over things
Peer problems
Perfectionistic
Poor Grades
Shy
Sleeplessness
Has trouble following directions
Other: ______________________________________________________________________
Has the child/adolescent experienced any significant loss? If yes, explain: _________________________
_____________________________________________________________________________________
What are your child/adolescent’s interests and activities?
_____________________________________________________________________________________
What are your child/adolescent’s responsibilities at home?
_____________________________________________________________________________________
How well does your child/adolescent’s handle these responsibilities?
____________________________________________________________________________________
_____________________________________________________________________________________
Briefly describe your goals for your child/adolescent’s therapy:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
I hereby consent for Heidi Cutler, LCSW-R to provide my child/adolescent with evaluation and
treatment.
_____________________________________________________________________________________
Signature
Date