Child Intake About Child Family Members Family History School Milestones Health History Name Name of Person Completing Form * Relationship to Child * Mother Father Parent Stepmother Stepfather Grandparent Guardian Sibling Other Email * Child's Email (if applicable) Emergency Contact * Emergency Number * Emergency Contact Address (if not a parent) Child's First Name * Child's Last Name * Child's Birth Date * Child's Gender Identity * Female Male Transgender FTM Transgender MTF Questioning or Other Child's Preferred Pronouns She/hers/her he/his/him they/their/them ze/hir/hir other Insurance Company * Wellmark/Blue Cross Blue Shield of Iowa Wellmark/Blue Cross Blue Shield (Out-of-State): please check your benefits!!! Blue Cross/Blue Shield (Anthem or Federal): please check your benefits!!! Healthpartners (UnityPoint) Other - we are out-of-network; services will be private pay. Evaluations are $4000; Therapy is $175/session. Policy Number * Group Number * Child's Current School Child's Current Grade No schooling Preschool Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade Some College Associate Degree Bachelor's Degree Master's Degree Doctorate Degree Child's Pediatrician Who referred you to our office? * What is the reason for seeking help for your child? How has the family attempted to deal with these concerns? What are your child's strengths? What does your child like to do? Does your child (select all that apply)... get along with other children? get along with adults? engage in imaginative play activities? have friends? keep friends? understand gestures? have a good sense of humor? understand social cues such as when others are angry? feel uncomfortable, need support? have problems with peer pressure? Child's Biological Parents Married Living together Separated Divorced Never lived together Remarried Amicable Conflictual Other Custody Arrangements Shared physical custody Shared legal custody Full legal custody with parent/guardian 1 Full legal custody with parent/guardian 2 Primary physical custody with parent/guardian 1 Primary physical custody with parent/guardian 2 Other Parent/Guardian 1 Parent/Guardian 1 Sibling 1 Sibling 1 Problems with attention, hyperactivity or impulse control Mother Mother's Family Father Father's Family Siblings Other Problems with aggression, defiant and oppositional behavior as a child Mother Mother's Family Father Father's Family Siblings Other Learning Disabilities Mother Mother's Family Father Father's Family Siblings Other Arrests / antisocial behavior Mother Mother's Family Father Father's Family Siblings Other Mental Retardation Mother Mother's Family Father Father's Family Siblings Other Autism Mother Mother's Family Father Father's Family Siblings Other Depression for longer than two weeks Mother Mother's Family Father Father's Family Siblings Other Suicidal thoughts or attempts Mother Mother's Family Father Father's Family Siblings Other Bipolar Disorder Mother Mother's Family Father Father's Family Siblings Other Anxiety Disorder (worry, nervousness, panic) Mother Mother's Family Father Father's Family Siblings Other Obsessive-Compulsive Behavior Mother Mother's Family Father Father's Family Siblings Other Eating Disorder Mother Mother's Family Father Father's Family Siblings Other Psychosis or Schizophrenia Mother Mother's Family Father Father's Family Siblings Other Alcohol abuse or dependence Mother Mother's Family Father Father's Family Siblings Other Drug abuse or dependence Mother Mother's Family Father Father's Family Siblings Other Victim of physical abuse Mother Mother's Family Father Father's Family Siblings Other Victim of sexual abuse Mother Mother's Family Father Father's Family Siblings Other Name of child's teacher(s) Teachers' email * Describe your relationship with your child's teacher? Principal? Name of child's preschool (if applicable) Has this child ever had any evaluation for learning disabilities, speech/language concerns, or motor concerns? Has your child ever had any evaluation for learning disabilities, speech/language concerns, or motor concerns? At what age did your child walk? At what age did your child say their first word? At what age did your child put 2-3 words together? At what age did your child toilet train for bowel movements? At what age did your child toilet train for bladder? At what age did your child sleep through the night? Signs of language concerns Articulation concerns Difficulties with phonics Difficulties pronouncing new words Talking too fast Talking too slow Mumbling Garbled speech Saying the same word over and over Talking too loudly Talking too soft Breathy or nasal voice Difficulties explaining ideas to others Difficulties following instructions or commands Difficulties finding words Stuttering Signs of fine motor concerns Difficulties with handwriting Difficulties with scissors Difficulties with folding Awkward or immature pencil grasp Slow or laborious drawing, coloring or writing skills Slow or laborious drawing, coloring or writing skills Difficulty performing manipulation tasks (i.e. doing up buttons, etc.) Difficulties tying shoes Difficulty with new fine motor tasks Tires easily on fine motor tasks Does your child display any of the following oral motor problems? Drooling Poor sucking Poor chewing Overstuff his/her mouth when eating Have an open mouth posture Have a protruding tongue Swallow without chewing Grind his/her teeth during the day Mother used alcohol during pregnancy Never Rarely Once per week Once daily More than once per day Mother used nicotine during pregnancy Never One or two daily Half pack daily One pack daily More than one pack per day Mother consumed caffeine during pregnancy Never Rarely Once per week Once daily (8 ounces or less of coffee or pop) More than once per day Mother used street drugs during pregnancy Never Once or twice Rarely Often Frequently Medication mother used during pregnancy Valium, Xanax, Anti-anxiety medications Cannabis Antidepressants Anti-seizure Medications Antipsychotics Tranquilizers or sleep aids Diabetes Treatments Antibiotics Thyroid medications Antihistamines Decongestants Steroids Melatonin Iron shots or supplements Anti-nausea medications Any other medications taken during pregnancy? Delivery was Vaginal Caesarean Baby was Full-term: 36 weeks or more Overdue Premature Birth weight Apgar Rating if known (immediately and after 3 minutes) Good social support for parents and baby? Yes No Sometimes During pregnancy, check all that apply Did mother receive prenatal vitamins? Did mother experience extreme stress during pregnancy? Any illnesses during pregnancy? Any complications during labor and delivery? Any health problems for infant during birth? Is your child currently taking any medication? Is your child currently taking any medication? Head/Neurological Motor Tics Verbal Tics Complex Tics Seizures Head Trauma History of Loss of Consciousness 1-2 times History of Loss of Consciousness 3-4 times History of Loss of Consciousness more than 4 times Sensory Disturbances Repetitive head banging Severe Headaches Migraines TIA Eyes Vision loss due to injury Blindness Cataracts Glaucoma Glasses/contacts for Nearsightedness Glasses/contacts for Farsightedness Visual Convergence Concerns Ears/Nose/Sinus/Throat History of ear infections Tubes in ears Hearing Problems Allergies Sinus infections Recurrent Tonsillitis/Strep Throat Tonsils Removed Adenoids Removed Hematology/Oncology Anemia Cancer Kidney/Urinary Frequent UTI's Kidney Stones Daytime wetting Bedtime wetting Endocrine Concerns Autoimmune Disorder Diabetes Type 1 Diabetes Type 2 Hypothyroidism Hyperthyroidism Heart/Lungs Heart Murmur Dysrhythmia Heart Disease Asthma Recurrent Bronchitis Gastrointestinal Frequent Stomachaches GERD Gallbladder problems Food Intolerances Food allergies Frequent Diarrhea Irritable Bowel Syndrome Crohn's Disease Frequent Constipation Musculoskeletal Clumsy Lack of fine motor coordination Lack of gross motor coordination Arthritis Multiple Sclerosis Cerebral Palsy Please describe any health issues that were not listed above n/a Food or Eating Issues Very fussy eater Avoids certain textures or flavors Eats only meat Eats very few foods Eats mostly carbohydrates Gluten free diet Vegetarian diet Food allergies Eats only dairy Very slow eater Very fast eater Drinks lots of caffeine Eats many sugary foods Willingly eats fruits and vegetables Has your child had any of the following? Weight gain Weight loss Healthy weight Underweight Overweight Has your child experienced or been exposed to any of the following? Parental neglect Parental abandonment Verbal abuse Emotional abuse Physical abuse Sexual abuse Exposure to unwanted pornography or violence through print or media Victimized through peer bullying (verbal or physical) Exposure to drugs in the home Trauma Does your child have any of the following sleep problems? Hard to go to sleep Wakes up throughout the night Wakes up too early in the morning Chronic snoring Nightmares Can't wake up in the morning Sleeps in parents' bed all night Afraid to go to sleep Electronics in room Uses electronics up to bedtime Gets up after bedtime to use electronics Wakes up and eats throughout the night Night terrors Very physically active in sleep What is the quality of your child's health? Excellent Good Average Poor List any surgeries or hospitalizations (include reasons and dates) n/a
