CHILDREN FIRST
INITIAL EVALUATION
(complete after 1st session with parent)
Client:
Date:
Date of Birth:
Gender:
Therapist/Evaluator:
Race/Ethnicity:
Returning Client:
Sources of Information: (names and relationship to client ie: parent, teacher, etc.)
Presenting Problem: (brief history, precipitating events)
Client Strengths, Skills, Interests, Involvement in School Activities:
Family History and Functioning: (may include genogram)
Cultural Assessment: (age, development, disability, religion, ethnicity(race), sexual orientation, socioeconomic
status, indigenous heritage, national heritage, gender identity)
EDUCATIONAL INFORMATION:
Grade:
Name of School:
Current Grades/GPA:
Attendance Issues:
Quality of Relationships with School Staff: (cooperative, withdrawn, defiant, other)
Quality of Relationships with Peers at School: (friendly, aggressive, victimized, bullies, other)
08/15
11.5
Identified Learning Problems:
IEP:
Yes
No
School Behaviors: (enjoys school, follows rules, inattention, disruptive behaviors, withdrawn, other)
Educational and Career Goals:
PSYCHOSOCIAL RISK ASSESSMENT OR FACTORS:
Circle best response and include additional information in comments section
Failure to thrive:
Child abuse/sexual abuse/neglect
Exposure to Domestic Violence
History of out-of-home placement
At risk of out-of-home placement
Exposure to community violence
Victim of community or other violence
Unsafe neighborhood
Homeless
Living in poverty
Parental divorce or separation
Loss of parent to (circle one):
Death
Incarceration
Deportation
Familial substance abuse
Serious illness in family
Caregiver developmental disability
Family history of mental illness
Impulsivity/acting out bxs
Legal difficulties
Sexual acting out
Lack of Resources (please list)
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Current
Current
Current
Current
Current
Current
Current
Current
Current
Current
Current
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
Past
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Current
Current
Current
Current
Current
Current
Current
Current
Current
Past
Past
Past
Past
Past
Past
Past
Past
Past
Comments:
Current danger to self:
High
Moderate
Low
None
Current danger to others:
High
Moderate
Low
None
Current impulsivity:
High
Moderate
Low
None
PRESENT MENTAL, PHYSICAL, DENTAL HEALTH STATUS (include dates of last physical, dental, etc.):
PREVIOUS COUNSELING (include voluntary/involuntary hospitalizations, suicidal behavior, other):
08/15
PRELIMINARY DIAGNOSIS:
ICD-10-CM
DISORDER (including DSM-5 Specifiers)
OTHER CONDITIONS THAT MAY BE A FOCUS OF CLINICAL ATTENTION:
CONDITION/PROBLEM:
Z
Z
Z
Z
Parent/Guardian Signature
Therapist Signature (with credentials)
Supervisor Signature
08/15