HOPEFUL HEARTS COUNSELING
2211 Peoples Road Suite C
Bellevue, NE 68005
Voice: (402) 916-9886 Fax: (888)754-4926
PRETREATMENT ASSESSMENT (ages 18 and under)
DATE COMPLETED:
Client's Name:
Gender:
Date of Birth:
Age:
Grade:
Form Completed by (if someone other than client):
Address:
City:
State:
Zip:
Phone:
SSN:
INS :
If you need more space for the following questions please use the back of the sheet.
Primary Reason(s) for Seeking Services: Circle all that apply and/or complete the other mental health
concern area:
Anger Management _Anxiety _Coping _Depression_Eating Disorder _Fear/Phobias _Mental Confusion
Social Concerns _Sleeping Problems_ Addictive Behaviors_Alcohol/Drugs _Hyperactivity
Other Mental Health Concerns:
Family Information:
Mother (Name, age, location of residence)
Father (Name, age, location of residence)
Siblings (Name, age, location of residence)
Significant Others:
Mother's Occupation:
Where Employed: Work Phone:
Number and Dates of Marriage(s):
Father's Occupation:
Where Employed and Work Phone:
Number and Dates of Marriage(s):
Parents married? No If Yes when and how long:
Parents separated? No If Yes when and how long:
Parents divorced? No If Yes when and how long:
Child raised by someone other than biological parents? No If Yes who, why and how long?
State intervention(s) If Yes when and why and how long?
DISCIPLINE
How does the mother discipline the child?
For what reasons is the child disciplined by the Mother?
How does the father discipline the child?
For what reasons is the child disciplined by the Father?
DEVELOPMENT
Has the Mother had any miscarriages or stillborn children? If Yes, describe circumstances:
Was the pregnancy planned? Yes /No; Length of Pregnancy:
Mother's age at Birth and Father's age at Birth of Child:
How many pounds did the Mother gain?
Did Mother smoke during pregnancy? If yes how much?
Did Mother use drugs or alcohol? If yes, how much?
Did Mother have emotional or medical difficulties during pregnancy? If yes describe:
Length of labor:
Natural/ Induced/ Caesarean/Vaginal:
Baby's birth weight:
Baby's Birth length:
INFANCY/TODDLERHOOD Circle all that applies:
Breast Fed
Milk Allergies
Vomiting
Diarrhea
Bottle Fed
Rashes
Constipation
Not cuddle
Cried often
Rarely Cried
Overactive
Resisted Solids
Trouble Sleeping
Irritable when awake
Colic
Lethargic
Describe any emotional or medical complications with delivery:
Describe any complications for the mother or baby after birth:
Length of hospitalization for Mother and for Baby:
Are there any special, unusual, or traumatic circumstances that affected child's development? If Yes,
please describe:
DEVELOPMENTAL MILESTONES: Please note the age at which the following behaviors took place:
Sat alone:
Dressed self:
Spoke full words:
Weaned:
Took 1st steps:
Rode two wheel bike:
Dry during day:
Ties shoe laces:
Spoke sentences:
Fed self:
Compared to other in the family, this child's development was:
Toilet trained:
Dry during night:
slow
average fast
Age for following developments (if applicable)
Began Puberty/Menstruation /Voice change:
Problem behaviors:
Vocation/Job:
Has there been a history of child abuse? If yes what kind? (Please circle all that applies) Victim, Physical,
Sexual, Mental, Emotional, Neglect
Perpetrator? Physical Sexual Mental Emotional Neglect
Any additional information on development?
SOCIAL RELATIONSHIPS
Circle how this child generally gets along with other people (all that apply):
Affectionate
Leader
Aggressive
Outgoing
Avoidant
Fight
Shy/withdrawn
Argue often
Submissive
Follower
Other (specify):
Friendly
LEISURE and RECREATIONAL
Describe areas of interest or hobbies and any changes in them:
HOW OFTEN IN THE PAST? NOW?
CUL TURAL and ETHNIC
To what ethnic or cultural group, if any, does this child identify with?
Are there any issues surrounding this affiliation?
SPIRITUALITY AND RELIGION
Are you affiliated with a spiritual or religious group? If Yes please describe:
If Yes, name of church or meeting place?
How important is your Spiritual or Religious beliefs to you?
Were you raised within a Spiritual or Religious affiliation? If Yes please describe:
EDUCATION
Location Age(s)
Has child ever been suspended from school? If Yes please describe when, where, why:
LEGAL CURRENT STATUS
Are you involved in any active cases? If Yes please describe with indicate court dates and charges:
Are you currently on probation or parole? If Yes please describe:
PAST HISTORY
Traffic Violations: Date __ DWI, DUI, ETC If Yes-Date:
Criminal Involvement: If Yes-Date and Reason
Civil Involvement: If Yes-Date and Reason
Please elaborate on any Yes answers:
VOCATION
Does the child work? If Yes, please describe job, dates, hours and duties:
What is the child's attitude towards work?
Has this gotten better or worse in the last 6 months?
Has the child's grades been affected since working? If yes, how?
How many jobs has the child had?
Usual Length of employment by one institution?
MEDICAL and PHYSICAL HEALTH
(PLEASE CIRCLE ALL THAT HAVE APPLIED)
Abortion
Bronchitis
Congenital Problems
Diphtheria
Hepatitis
Lead Poisoning
Miscarriage
Muscular Dystrophy
Scarlet Fever
Severe Head Injury
Asthma
Cerebral Palsy Croup
Eczema
Hay fever
Hives
Measles
Multiple Sclerosis
Pleurisy
Pregnancy
Seizures
Sexually Transmitted Dis.
Chicken Pox
Diabetes
Ear Aches
Encephalitis
Meningitis
Mumps
Other skin rashes
Severe Colds
Thyroid disorders
Paralysis
Nose Bleeds
Blackouts
Influenza
Rheumatic Fever
Wearing Glasses
Whooping cough
Other (Please describe)
Are there any current health concerns?
Are there any recent physical or health changes?
NUTRITION
Breakfast Number of times a week?
How much eaten?
Morning Snack Number of times a week? How much eaten?
Polio
Dizziness
Heart Problems
Pneumonia
Vision Problems
Ear Infections Fevers
Foods normally eaten?
Lunch Number of times a week?
How much eaten?
Foods normally eaten? _
Afternoon snack Number of times a week?
How much eaten?
Dinner/Supper Number of times a week?
How much eaten?
Foods normally eaten?
Evening snack Number of times a week? How much eaten?
Favorite foods:
Food allergies: If Yes, what and result:
MEDICATIONS
Current Prescribed Medications (if more room is needed please use back of sheet):
Medication: Dosage: How long?
Are any over the counter medications taken regularly?
Medication: Dosage: Reason?
Are there any allergies to medications? If Yes please describe:
CHEMICAL USE STORY
Does the child/adolescent use or have a problem with alcohol and drugs? If Yes please describe:
COUNSELING PRIOR TREATMENT HISTORY
Are you currently receiving counseling services? If Yes please provide where, how long, and why:
Has the child previously received any mental health services in the past? If Yes, please provide when,
how long, and reasons:
Do you feel that this child is currently in any danger of abuse, neglect, or suicidal ideation or homicidal
ideation? If Yes, please describe:
What is the main reason(s) for request for services?
How long has this/these problems persisted?
Under what conditions do these problems get worse?
Under what conditions do these problems seem to get better?
How did you hear of this clinic or who referred you?
Name and address of child's primary physician:
List any operations child has ever had and when:
Last doctor’s appointment and reason:
Last physical and results:
Are all immunizations current and up to date?
BEHAVIORAL AND EMOTIONAL INFORMATION:
Please CIRCLE all that are typical for this child:
Affectionate
Aggressive
Alcohol problems
Angry Anxiety
Attachment to dolls
Avoids adults
Bedwetting
Blinking, jerking
Bizarre behavior
Bullies, threatens
Careless, reckless
Cooperative
Chest pains
Cyber addiction
Difficulty speaking
Clumsy
Confident
Defiant
Depression
Eating disorder
Memory problems
Gambling
Generous
Hopelessness
Hurts animals Imaginary friends
Learning problems
Messy
Sad
Selfish
Frustrates Easily
Hallucinations Head banging Heart Problems
Lies frequently
Moody
Destructive
Impulsive
Listens to reason
Nightmares
Separation Anxiety
Irritable
Lazy
Loner Low self-esteem
Obedient
Oppositional
Over active
Sets fires
Sexual addiction
Sexual acting out
Shares
Sick often
Short attention span
Shy, timid
Sleeping problems
Slow moving
Soiling
Speech problems
Steals
Stomach aches
Suicidal threats
Suicidal attempts
Talks back
Teeth grinding
Thumb sucking
Tics or twitching
Please elaborate on concerning behaviors:
List at least three strengths of this child:
1)
2)
3)
Please list at least three areas if improvement:
1)
2)
3)
What things does this child associate or play with?
What information, if any, do you feel that I should know prior to working with this child or that would
help me to better understand this child?
Do you have any questions of me before working with this child?
Thank you for the opportunity to work with you and the child you care for.