Interview Questions Patient Name: Who is answering these questions: Date: When answering these questions, please provide some examples when appropriate. 1. Describe why you are requesting this Assessment: (include examples of the problem) How long have the problems been going on. When did you start noticing them. What situations do you notice the problem? (Home, school Etc.) Is there anything that you have noticed that triggers the problem? What effect has the problem had on daily life at home, school, social etc? How aware is the child of the problem? How do they react to the problem? How do they cope with their symptoms? What do you think may be causing the problem? What have you done to resolve the problem so far, if anything? If you have tried things, what has worked and what hasn’t? 2. Education/Work How long at current school? If changed, how did they respond to the change? How old were they when they learned to read? Any struggles with it? What is current and history of grades: What subject are they good at and not so good at? Which (if any) subjects have been difficult for them consistently throughout their academic years? What attitude and/or approach does your child have to their homework? (seems to take too long, rushes through, has missing assignments, etc.) Does the child like school? What do the teachers/principals have to say about them? Any behavioral problems in school? If so, describe them and what has been done about them so far. What has been done at school to accommodate behavior and or cognitive problems? (504 or IEP) What, if any extracurricular activities are they involved in? Any career aspirations yet? If so, what are they interested in. Any work experiences? Describe where, length, relates to others, success and failures. 3. Developmental History Anything remarkable about Pregnancy? Describe Labor and Delivery Apgar Scores- normal or list problems Milestones: (give approximate age) Sitting: Walking: Crawling: Talking: Potty Training: Last time wet the bed: Any interesting things I should know about regarding their developmental progress? Describe the following: -Baby’s temperament (laid back, fussy, etc.) and current temperament/personality (outgoing, quiet, anxious, type A, etc.) -Ability to be soothed (took forever for baby to calm down, or calmed down immediately, etc.) -Discuss any separation anxiety with baby sitters, going to school, etc. -How did they transition to any new siblings 4. Health Describe history such as ear infections, surgeries, broken bones, head injuries, concussions, seizures, chronic problems (diabetes, etc.), stitches, etc. Current physical complaints (headaches, stomachaches, dizziness, always cold or hot, etc.) and frequency Current Medications if any: Approximately when was last physical including eyes and hearing checked Family mental health history along with physical health issues (learning disabilities, emotional issues, immunological diseases, diabetes, thyroid, etc.) Any history or current speech problems? If so what kind and what was done about it. Current Eating: Current Sleeping (troubles waking up and/or falling asleep, gets up often middle of night, sleeps in parents room, naps, nightmares, etc.) Current Energy Level: Sensory Issues (sensitivity to certain fabrics, tags, textures, tastes, noises, light etc.) Motion Sickness: Hand Dominance: Right or Left. Any problems determining which hand was dominant? Any difficulty with learning where right and left is? Describe physical coordination skills- I.E. Clumsy, trouble doing sports, etc. Any difficulty with fine motor skills- I.E tying shoe laces, poor handwriting, etc. Describe any signs of puberty (menstruation, etc.) Any exposure to cigarettes, alcohol, drugs? 5. Mental Health History Describe Cognitive Abilities: -Memory: -Attention: -Planning/Organizing: -Motivation (in school or home): -Judgment: -Risk Taker: -Creativity: -Sense of Humor: Describe Emotional Disposition -Tantrums? If so, describe behavior and how long it lasts: -Sensitivity (i.e. do they cry easily, etc.) -What makes them angry and how do they respond? -Describe high or low frustration tolerance: -Describe any signs of perfectionism, obsessions, and rituals: -How often are they anxious, how do they act when anxious, what makes them anxious. -Describe any fears: -Moodiness (what is their overall mood like-sad, even, happy? Also, how often does the mood fluctuate? Do they go through periods where they seem too happy?) -Any suicidal ideation? If so, give specific examples and how this has been handled. -Any behavioral problems involving violence? -Any behavioral problems involving the law? -Any concerns with possible auditory or visual hallucinations? -Any other special behaviors I should know about? Social Skills- describe friends, how they interact with others, any long term relationships and any problems with friends or with reading social cues: Please describe any crisis or losses in their lifetime and how they handled it (death of loved one, death of pet, move to new school, divorce, etc.) Have there been any mental health treatment and or assessment in the past? When, where and for how long? What was the reason for treatment? What was the outcome? What did they like and dislike about it? 6. Home Environment Who is in family and who lives in the home? How long have they lived in home? Any pets? How are the pets treated? Any divorce? If so, describe parent’s relationships, custody arrangements, how long divorced, how child is adjusting. Describe the relationships the patient has with each family member: What does the child do to get disciplined: What discipline is used and how long is punishment? How does the child react to it? (Angry, remorseful, etc.) Is the discipline effective? Involvement with religion: What does the child do in leisure time? What are their interests and hobbies? 7. Parents History How long married and if applicable how long divorced? Describe how child might perceive the marital/divorce relationship: Parents education and careers? Any current stressors in the marital/partner relationship? Current individual stressors outside of the relationship? (ie financial problems, extended family illnesses, etc.) 8. General Describe your child’s overall strengths and weaknesses: What do you expect and or hope to gain from this evaluation and how do you think it will help your child. What will you tell the child why they are being tested? Is there anything else you feel I should know about your child?