Online Admission Packet
Children’s Program – Behavioral Health Services
Psychosocial and Family Assessment
IDENTIFYING INFORMATION
Date______________________________
(To be filled out by legal guardian or with their assistance)
_________________________________________________________________________________________________
Child’s first name
Middle name
Last name
Race ______________ Hospital where born _______________________________ Location _____________________
Child’s Address: _______________________________________City_______________________ State_____________
Zip Code ________ Child’s Home Phone number: _______________________ Child’s SS#:_________________________
Child’s birth date_________________ Child’s age________________
How long has the patient lived in the current location? _____________________________________________________
Where else has the patient lived in the past five years? _____________________________________________________
__________________________________________________________________________________________________
Who is the legal guardian of the child: _____________________________________________________________
Guardian's Address (if not parent & if different than child's) ________________________________________________
City __________________________ State_____ Zip Code__________ Guardian's Home Phone #__________________
Guardian's Work Phone #__________________ Guardian's Cell Phone #__________________
Emergency Contact ________________________________________
Name
Home #_______________________
__________________________
Relationship
Work #_________________________
Cell #___________________________
FAMILY HISTORY
How long were the biological parents together? __________________________________________________________
Are the parents currently: MARRIED
LIVING TOGETHER
SEPARATED
DIVORCED
If separated/divorced, when did the separation/divorce take place? ___________________________________
Have the parents had additional marriages?
YES
NO If “YES”, please identify date(s) of marriage(s) and divorce(s):
________________________________________________________________________________________________
Does the child have contact with both biological parents? YES
NO, why? ________________________________
_____________________________________________________________________________________
Is it okay to contact non-custodial parent? Yes No If no, explain ____________________________________
Biological parents married when child was born? YES
NO
If not together, date of parental separation (divorce, breakup, etc.)
_____________________________________
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Online Admission Packet
Name of Biological Father: ________________________________________DOB__________ SS#_______________
1. Parental rights terminated? NO YES WHEN
_____________________________________________________
2. Address_______________________________ City___________________ State_______ Zip Code ____________
3. Phone: home#______________________
cell# __________________________
wk#_______________
4. Employer______________________________ Occupation___________________________
5. Level of Education: Dropped out
H.S.
Trade
Bachelor Master’s PhD/MD Other:____________________
6. Mental illness, father or family? NO YES:____________________________________________________________
_____________________________________________________________________________________________
7. Substance abuse, father or family? NO YES: _______________________________________________________
8. Any learning disabilities in family? NO YES: ________________________________________________________
9. Military service history: NO YES: _______________________________________________________________
10. Any previous marriages? NO YES: ____________# of kids from previous marriage: _______________________
11. How did parent get along with own parents? ________________________________________________________
12. How does child get along with him? _______________________________________________________________
Name of Biological Mother: ________________________________DOB____________SS#_____________________
1. Parental rights terminated? NO
YES WHEN _____________________________________________________
2. Address_______________________________ City__________________ State_________ Zip Code ____________
3. Phone: home#______________________
cell# __________________________
wk#__________________
4. Employer______________________________ Occupation___________________________
5. Level of Education: Dropped out
H.S.
Trade
Bachelor Master’s PhD/MD Other:___________________
6. Mental illness, mother or family? NO YES:___________________________________________________________
_______________________________________________________________________________________________
7. Substance abuse, mother or family? NO YES: _______________________________________________________
8. Any learning disabilities in family? NO YES: ________________________________________________________
9. Military service history: NO YES: _________________________________________________________________
10. Any previous marriages? NO YES: ____________ # of kids from previous marriage: ________________________
11. How did parent get along with own parents? _________________________________________________________
12. How does child get along with her? ________________________________________________________________
Other Adult involved with patient: ____________________________DOB_____________SS#__________________
Relationship to child: Adoptive Parent Step Parent
Legal Guardian Foster Parent Or: _______________
1. Address_______________________________ City____________________ State______ Zip Code ______________
2. Phone: home#______________________
cell# __________________________
wk#___________________
3. Employer______________________________________ Occupation_______________________________________
4. Level of Education: Dropped out
H.S. Trade
Bachelor Master’s PhD/MD Other:____________________
5. Mental illness, parent or family? NO YES:___________________________________________________________
6. Substance abuse, parent or family? NO YES: _______________________________________________________
7. How does child get along with _____________________________________________________________________
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Online Admission Packet
Other adult involved with patient: _________________________DOB_____________SS#______________________
Relationship to child: Adoptive Parent
Step Parent
Legal Guardian Foster Parent
Or:_______________
1. Address_______________________________ City___________________ State_______ Zip Code _______________
2. Phone: home#______________________
cell# __________________________ wk#_______________________
3. Employer_______________________________________Occupation_______________________________________
4. Level of Education: Dropped out
H.S.
Trade
Bachelor Master’s PhD/MD Other:____________________
5. Mental illness, parent or family? NO YES: ____________________________________________________________
6. Substance abuse, parent or family? NO YES: _________________________________________________________
7. How does child get along with _____________________________________________________________________
Who is responsible for child’s discipline ___________________________________________________________________
Place a check by any of the following methods used
 Time out
 Restrictions
 Loss of privileges
 Spanking
 Limited choices
 Praise
 Rewards
 Other __________________________________________________________________________________________
Is there a Guardian Ad Litem involved? Name____________________________________ phone#___________________
How long has the involvement been? _____________________________________________________________________
Siblings:
(H-Half, F-Full, S-Step, A-Adoptive)
Name
Gender
Age
Relationship
Where do they live
1) ___________________________________
M F
____
H F S A
_______________________________
2) ___________________________________
M F
____
H F S A
_______________________________
3) ___________________________________
M F
____
H F S A
_______________________________
4) ___________________________________
M F
____
H F S A
_______________________________
Relationship with siblings: ____________________________________________________________________________
__________________________________________________________________________________________________
Who is currently living in the home? _____________________________________________________________________
___________________________________________________________________________________________________
Is there any information that cannot be disclosed to the patient at this time?
NO
YES (explain) ___________
___________________________________________________________________________________________________
____________________________________________________________________________________________________________
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Online Admission Packet
CURRENT LEVEL OF FUNCTIONING
Behavioral Profile (Put a star beside any behavior that has occurred in past month) If it is not a problem
write NO for that question.
Describe any suicidal or self-harming behavior: ____________________________________________________________
__________________________________________________________________________________________________
_________________________________________________________________________________________________
Describe any homicidal or assaultive behavior(onset, triggers) : ______________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Describe any depression (onset, duration, what makes it worse): _____________________________________________
__________________________________________________________________________________________________
Describe any psychotic behavior (onset, duration, triggers): ________________________________________________
_________________________________________________________________________________________________
Describe the child’s usual mood: ______________________________________________________________________
__________________________________________________________________________________________________
Describe any mood swings: __________________________________________________________________________
_________________________________________________________________________________________________
Describe any significant losses: _______________________________________________________________________
Describe any pyromania (fire setting): __________________________________________________________________
_________________________________________________________________________________________________
Describe any stealing: _______________________________________________________________________________
_________________________________________________________________________________________________
Describe any cruelty to animals: ______________________________________________________________________
_________________________________________________________________________________________________
Describe any verbal abuse/swearing: __________________________________________________________________
_________________________________________________________________________________________________
Describe any history of temper tantrums (If previous, when tantrums stopped?):______________________________
_________________________________________________________________________________________________
Describe any destruction of property/vandalism: _________________________________________________________
_________________________________________________________________________________________________
Describe any day or night time wetting, soiling clothes, or urinating in inappropriate places: _______________________
_________________________________________________________________________________________________
Describe extent of any alcohol use or drug use or smoking: _________________________________________________
_________________________________________________________________________________________________
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Online Admission Packet
Describe any lying: ________________________________________________________________________________
_________________________________________________________________________________________________
Describe any running away: __________________________________________________________________________
_________________________________________________________________________________________________
Describe any poor hygiene: __________________________________________________________________________
_________________________________________________________________________________________________
Describe any impulsive behavior (doing without thinking): __________________________________________________
_________________________________________________________________________________________________
Describe any problems with memory or concentration (onset): ______________________________________________
_________________________________________________________________________________________________
Describe any risky behavior: _________________________________________________________________________
_________________________________________________________________________________________________
Describe any problems playing with others (is child invited to others’ houses for day, overnight?): ___________________
_________________________________________________________________________________________________
Describe any problems with peer group (what is typical relationship like with peers?):
_________________________
_________________________________________________________________________________________________
Describe any inappropriate sexual behavior (public masturbation, fondling, exposing self, etc.):_____________________
_________________________________________________________________________________________________
How has the family reacted to the patient’s problems?
___________________________________________________
_________________________________________________________________________________________________
PAST TREATMENT HISTORY
Where has the patient received therapeutic services in the past? (Most recent first, I-Inpatient, O-Outpatient)
Name of Agency/Therapist
Dates
Level
Primary Referring Problem(s)
1)
______________________________
__________
I O
_______________________________________
2)
______________________________
__________
I O
_______________________________________
3)
______________________________
__________
I O
_______________________________________
4)
______________________________
__________
I O
_______________________________________
5)
______________________________
__________
I O
_______________________________________
Other services received: (and reasons previous services were stopped)
Case Management: __________________________________________________________________________________
In Home Family Based Services/Dates: _________________________________________________________________
Parenting Classes/Dates:
________________________________________________________________________
Neurological Evaluations/Dates: ________________________________________________________________________
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Online Admission Packet
Any Psychological Testing done? NO YES _______________________________________________________
When: _________________________ Where:___________________________ By whom:_________________________
Why: ____________________________________________________________________________ I.Q.______________
Who referred you to the Children’s Program? _________________________________________________
CHILD'S MEDICAL HISTORY
List any drug allergies_________________________________________________________________________________
Child’s current height __________________________ Child’s current weight ___________________________________
Child’s family doctor _____________________________ Office name____________________ Phone #_______________
Has your child had problems with any of the following:
Three or more ear infections? NO YES ___________________________________________________________________
Difficulty urinating or urinary infections? NO YES __________________________________________________________
Constipation? NO YES __________________________ Diarrhea? NO YES _______________________________________
Seizures/convulsions NO YES __________________________________________________________________________
Describe any sleep problems: (onset, what makes it worse, frequency of problem) ____________________
_____________________________________________________________________________________
Describe any appetite problems (onset, what makes it worse, frequency of problem): _________________
Describe your child’s eating habits/preferences______________________________________________________________
Has your child had a change in appetite? NO YES
____________________________________________________________
Does your child follow a special diet? NO YES
_______________________________________________________________
Have there been any weight changes in last six months? NO YES
_______________________________________________
Does your child have any food allergies? NO YES
____________________________________________________________
Does your child wear braces or a retainer? NO YES _________________________________________________________
Who is your child’s orthodontist? _________________________________________________________________________
Has your child had recent cavities or tooth pain? NO YES
______________________________________________
When was your child’s last dental visit? ________________ Name of dentist ______________________________________
Hearing problems? NO YES _____________________________________________________________________________
Date/Place of last hearing test___________________________________________________________________________
Vision problems? NO YES
_______________________________________________________________________________
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Online Admission Packet
Date/Place of last vision exam ___________________________________________________________________________
Allergies NO YES ____________________________________________________________________________________
Check if the child has had any of the following illnesses and when.
If none of these check here 
 Roseola _____________
 Red Measles____________
 German measles (Rubella) _______________
 Mumps ____________
 Chicken Pox __________
 Asthma _____________
 Pneumonia ___________
 Broken Bones ________________________________
 Jaundice ____________
Whooping cough ____________
 Tonsils removed ______________________________  Adenoids removed __________________________________
Describe any significant illnesses_________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
List any hospitalizations (reasons, dates, age of child) _______________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
List any outpatient surgeries (reasons, dates, age of child) ___________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Has your child had a head injury in the past? NO YES When__________________________________________________
Loss of consciousness? NO YES Describe _________________________________________________________________
Has your child had any of the following tests? If so, please state why, when and where.
MRI
NO YES ______________________________________________________________________________________
____________________________________________________________________________________________________
CT scan
NO YES ___________________________________________________________________________________
____________________________________________________________________________________________________
EEG (test for seizures) NO YES _________________________________________________________________________
____________________________________________________________________________________________________
Check any of the following that the child’s biological family members have had (include parents, siblings,
grandparents, aunts, uncles and first cousins) Write the relationship on the line beside the illness.
 Asthma _____________________  Seizures _____________________
 Depression ________________________
 Diabetes ____________________  Tuberculosis __________________  High blood pressure _________________
 Bipolar illness ________________  Genetic disease _______________  Anxiety ___________________________
 Drug abuse __________________  Alcohol abuse ________________
 High cholesterol ____________________
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Online Admission Packet
 Heart disease before the age of 35 (for example: sudden cardiac death or fainting (syncope). If yes, please describe in
detail_______________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
List child’s current medication/dosage, who prescribes them and why it is taken
Medication_________________________ Dose_____________ Times___________________ Doctor_________________
Response _______________________________________________ how long on med _____________________________
Reason for med ______________________________________________________________________________________
Medication_________________________ Dose_____________ Times ____________________Doctor________________
Response________________________________________________ how long on med_____________________________
Reason for med_______________________________________________________________________________________
Medication_________________________ Dose_____________ Times ____________________Doctor________________
Response______________________________________________ how long on med_______________________________
Reason for med_______________________________________________________________________________________
Medication_________________________ Dose_____________ Times ____________________Doctor________________
Response _______________________________________________ how long on med______________________________
Reason for med __________________________________________________________________________
List any medications your child has taken in the past, when it was taken and why it was stopped
1. _____________________________________________________________________________________________
2. _____________________________________________________________________________________________
3. _____________________________________________________________________________________________
4. _____________________________________________________________________________________________
5. _____________________________________________________________________________________________
6. _____________________________________________________________________________________________
7. _____________________________________________________________________________________________
CHILD'S DEVELOPMENTAL HISTORY
Was pregnancy planned? NO YES
Birth weight ______________________ Full term or early ___________________
Problems during pregnancy/birth? NO YES: ________________________________________________________________
Any history of prenatal substance exposure?
Any history of postpartum depression?
NO YES: ____________________________________________________
NO YES: ___________________________________________________________
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Online Admission Packet
History of miscarriages/abortions prior to this delivery? NO YES
_________________________________________________________________________________________________
Birth - infancy
Any negative responses to separation from parents, feeding schedules, change? NO YES
___________________
___________________________________________________________________________________________________
What was the parent/child relationship during infancy? ______________________________________________________
Any family changes/stressful events during this time?________________________________________________________
Toddler years: (1 – 4 years old)
When did the child start walking? _________________ talking? __________________ toilet trained? _____________
Any toilet training problems/regressions? NO YES ________________________________________________________
Any behavior or temperament problems? NO YES ________________________________________________________
_________________________________________________________________________________________________
What age did you first notice problems in your child’s behavior?______________________________________________
What was the parent/child relationship? ________________________________________________________________
Any family changes/stressful events during this time?______________________________________________________
Childhood years: (five – twelve years old)
What was the parent/child relationship? ________________________________________________________________
Any family changes/stressful events during this time?______________________________________________________
Describe child’s strong points: _________________________________________________________________________
Did your child attend daycare? NO YES
What ages did they attend?_________________________________________
Any behavior problems? NO YES _____________________________________________________________________
NEGLECT AND ABUSE HISTORY
Any history of physical abuse?
NO YES _______________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Any history of sexual abuse (including rape)?
NO YES _________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________________________
Any history of neglect? NO YES _____________________________________________________________________
__________________________________________________________________________________________________
Any exposure to violence (movies or domestic violence)? NO YES___________________________________________
__________________________________________________________________________________________________
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Online Admission Packet
Has Social Services ever investigated the family or patient?
When?
NO
YES
Why?
Findings/Result of Investigation
1) ______________
___________________________
______________________________________________
2) ______________
___________________________
______________________________________________
EDUCATIONAL HISTORY
Current School _____________________________Current grade_______ Last school grade completed _____________
Name of primary school contact: _______________________________________________________________________
Type of educational disability if child is in special education
 LD (learning disability) grade started __________________________________________________________________
 EBD (emotional behavioral disabled) grade started _______________________________________________________
 EMD (educable mentally disabled. IQ 50 – 70) grade started ______________________________________________
 OHI (other health impairment) Reason_______________________ Example ADHD, bipolar disorder, medical conditions
When it started __________________________________________________________________________
Type of school classroom – please write when that placement started if other than a regular class
 Regular classroom education? ________________________________________________________________________
 Resource: How many periods per day? _________ When started?__________________________________________________
 Self – contained class room - When started?
______________________________________________________________
Has your child had any educational testing other than testing all children receive (standardized)? NO YES If yes, then
when and where?
_________________________________________________________________________________________
Special education services or 504 Plan? NO YES ___________________________________________________________
Does the child have an I.E.P.? NO YES __________________________________________________________________
Peer/Teacher Relations ______________________________________________________________________________
Preferred Learning Method:
Visual
Auditory
Tactile
Recent school performance (grades, behavior):___________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
How frequently is your child sent to the principal’s office? ___________________________________________________
How frequently are you called about your child’s school behavior? ____________________________________________
Has your child been suspended? NO YES ________________________________________________________________
Has your child ever repeated a grade? NO YES ___________________________________________________________
Number of days of school missed in past year?
0-5
6-10
11-15
>15
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Online Admission Packet
Past schools _______________________________________________________________________________________
__________________________________________________________________________________________________
 Speech therapy When___________________________ Where_____________________________________________
 PT (physical therapy) When_______________________ Where____________________________________________
 OT (Occupational therapy) When___________________ Where____________________________________________
*If available - Please enclose a copy of the psychological testing results, IEP or 504 Plan.
ENVIRONMENTAL AND CULTURAL FACTORS
Cultural and Spiritual Needs/Issues
Spiritual affiliation? __________________________________________________________________________________
Active in cultural or spiritual activities?
NO YES: _______________________________________________________
Cultural/environmental factors that may interfere with treatment? NO YES: __________________________________
____________________________________________________________________________________
Leisure/Recreation Interests
What are the patient’s interests/hobbies? ________________________________________________________________
__________________________________________________________________________________________________
Types of movies child likes to watch?_____________________________________________________________________
What kind of video games does your child like?_____________________________________________________________
Hours of TV, video games, computer per week?
<10
11-24
>25
Environmental Needs
Patient has stable housing?
Neighborhood safe?
YES
YES
NO: _____________________________________________________________
NO: ____________________________________________________________________
Do you receive your drinking water from a private well? YES NO __________________________________________
Are guns stored in the house? YES
NO
Are they locked up? YES NO
Other environment concerns?___________________________________________________________________________
__________________________________________________________________________________________________
Discharge Plans for after Residential Treatment: ____________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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Online Admission Packet
Available Community Resources
Put a check mark beside the support systems or community resources you have available to you – even if you do not use
them. Circle the ones that you use.
Church
Dept. of Social Services
Extended family
Big Brother/Big Sister
Continuum of Care
After school programs
Probation
Advocacy Group
Autism Society
Other
Mental Health Services
Neighborhood Community Center
Neighbors
Dept. of Disabilities & Special Needs
Other
MEDICAL INSURANCE INFORMATON
Medicaid number______________________________________________________
Primary insurance
Name of insurance company____________________________________________________________________________
Phone number_____________________________________ Group number______________________________________
Policy holder_______________________________________ Relationship to child_________________________________
Policy holder birth date__________________________ Policy holder SS # _______________________________________
Secondary insurance
Name of insurance company_____________________________________________________________________________
Phone number______________________________________ Group number______________________________________
Policy holder________________________________________ Relationship to child_________________________________
Policy holder birth date__________________________ Policy holder SS # _______________________________________
PLEASE INCLUDE THE FOLLOWING INFORMATION
*A CURRENT PICTURE OF YOUR CHILD
*A COPY OF YOUR CHILD’S IMMUNIZATION RECORDS
*A COPY OF CUSTODY PAPERS IF APPLICABLE
__________________________________________________________________________________________________
Signature of Person completing this form/relationship to child
Date/Time
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Online Admission Packet
__________________________________________________________________________________________________
Reviewing Nurses Signature
Date/Time
__________________________________________________________________________________________________
Reviewing Physician Signature
Date/Time
_________________________________________________________
Reviewing Therapist Signature
_______________
Date/Time
_____________________________________________________________________________________
Reviewing Teacher Signature
Date/Time
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