Psych EC Info Form

E-mail completed form to [email protected] SEATTLE CHILDREN’S or mail to Psychiatry Intake, DIVISION OF PSYCHIATRY AND BEHAVIORAL MEDICINE MS W-3636, PO Box 5371, EARLY CHILDHOOD Seattle, WA 98105-0371. PATIENT AND FAMILY INFORMATION FORM

IDENTIFYING INFORMATION Date Completed:

Child's Name: DOB: Ethnicity/race: Soc Sec #: Child’s primary language (if other than English): Gender: Male Female Parent’s primary language (if other than English): Person answering questions: Relationship: Person who assisted in completing this form: Who has current custody/guardianship of child? mother father both parents DSHS relative: other: If the Legal Guardian is someone other than the parents complete the following: Name: Relationship: Address: Phone:

INSURANCE INFORMATION

1. Insurance Plan Name (as written on card): Phone #: Employer: Subscriber Name: Subscriber birth date: Identification # Group # 2. Insurance Plan Name (as written on card): Phone #: Employer: Subscriber Name: Subscriber birth date: Identification # Group #

REASONS FOR EVALUATION Who referred you to Children’s Hospital: What are your primary concerns about your child/adolescent? When did your child/adolescent start having these issues? DE What services would you like to receive (please check all that apply)? Evaluation Only Medication Therapy Testing Other:

1 Please provide details about what you hope will result from services at Children’s: CAREGIVER INFORMATION

My child currently lives with: home with biological or adoptive family or relative foster care group care setting residential treatment facility other; if so, where

Parent/Caregiver Information: Relationship to child: mother father biological adoptive foster step other: Name: DOB: Address: Home Phone: Work Phone: Occupation: Employer: Marital Status: Years of Education/Degree:

Step Mother’s Name (if applicable): Step Father’s Name (if applicable): Emergency Contact: Relationship: Home Phone: Work Phone:

Please list other members of the child’s household (other than caregivers listed above): Name Gender Age Relationship M F M F M F M F

Please indicate the type of living situation in which the child resides: family home non-parent relative caregiver foster home other:

2 Is the child in the adoption process? Yes, already adopted Yes, in preadoptive placement No If yes, how old was the child when he/she was placed in the preadoptive/adoptive home? What was the child’s home/care environment prior to placement in the preadoptive/adoptive home?

Has the child been separated from his/her primary caregivers for significant periods of time? Yes No If yes, please provide information about the child’s age, circumstance, number of separations, and child’s response to each:

Is the child currently at risk for out-of-home placement? Yes No If yes, why:

BIRTH AND EARLY INFANCY HISTORY No information available about biological mother’s history This information should be provided as it relates to the biological parents of the child, if known. Was the pregnancy planned? Yes No Unknown Any difficulty becoming pregnant? If yes, please explain: How many pregnancies did the biological mother have? How many prior live born children did the biological mother have? Did the biological mother receive any prenatal care? Yes Limited None Unknown Was the mother exposed to any of the following while pregnant: None Unknown Before During Month(s) Type List Specific Substances Amount Pregnancy of Pregnancy Drugs Yes No Alcohol Yes No Tobacco Yes No Medications Yes No X-Rays Yes No

Did the mother experience any significant illnesses during pregnancy? Yes No Unknown If yes, please provide details:

Length of pregnancy: Age of mother: Weight gain: Describe labor and/or delivery with this child: Easy, no problems Difficult (please explain below) Natural (vaginal) C-section Forceps Please provide details on any labor/delivery problems: Were there any problems while the baby was still in the hospital? (For example, prolonged jaundice, need for incubator/oxygen, infections, feeding problems, convulsions):

Was the child in the Neonatal Intensive Care Unit? Yes No

3 Were there any difficulties during the baby's infancy? (e.g. excessive crying, health problems, recurrent vomiting, "colic", poor suck, low weight gain)?

Did parents have trouble adjusting to the new baby (e.g. post partum depression, anxiety)?

How would you describe the child’s temperament?

DEVELOPMENTAL HISTORY

Do you have any concerns about your child's development? Yes No. Do you perceive your child’s development as being average below average above average Has your child had any formal developmental testing or received any early intervention services? Yes No If yes, please provide details: Has your child received any Headstart or other early intervention services? Yes No If yes, please provide details about the services and provider(s):

At what age (in months) did your child first perform the following skills?

Smile at parent months not yet doing this Unknown Play peek-a-boo months not yet doing this Unknown Point to show something months not yet doing this Unknown Make good eye contact months not yet doing this Unknown Sit alone months not yet doing this Unknown Crawl months not yet doing this Unknown Stand alone months not yet doing this Unknown Walk with assistance months not yet doing this Unknown Walk alone months not yet doing this Unknown Make consonant-vowel sounds (e.g. “ba-ba”) months not yet doing this Unknown Use simple command such as “no” months not yet doing this Unknown Speak 2 to 3 word phrases months not yet doing this Unknown Speak full sentences months not yet doing this Unknown Drink from a cup months not yet doing this Unknown Eat with utensils months not yet doing this Unknown Respond to his/her name months not yet doing this Unknown Understand names of objects months not yet doing this Unknown Obey verbal commands (e.g. “come here”) months not yet doing this Unknown Get dressed by him/herself months not yet doing this Unknown

4 Tie shoelaces months not yet doing this Unknown Ride a 2-wheeled bike without training wheels months not yet doing this Unknown Daytime toilet trained (bladder) months not yet doing this Unknown Daytime toilet trained (bowel) months not yet doing this Unknown Nighttime toilet trained (bladder) months not yet doing this Unknown Nighttime toilet trained (bowel) months not yet doing this Unknown

Does your child have a predictable sleep schedule? Yes No For children ages 2 and older: Usual bedtime: Usual wake time: Describe any sleep concerns: Describe sleeping arrangements in the family:

SCHOOL/DAYCARE HISTORY

Is the patient currently enrolled in school? Yes No (If no, skip to next question) Please indicate your child’s attendance in the current and past quarter of school: On average, my child is missing less than one day per week of school On average, my child is missing more than one day per week of school Current school placement School District: Grade: School Name: Phone # Teacher/Counselor/IEP Coordinator: CHILD’S MEDICAL/PHYSICAL Is child enrolled in special education? Yes No Current IEP? Yes No (if yes, request copy) Child is designated: Seriously behaviorally disordered Learning disordered Health impaired Child’s classroom is: Regular Education Regular Education with pull-out to Resource Room Self- contained classroom Generic special education classroom Inclusion in regular education ( hours/day) Other: Describe current daily functioning in school setting (including strengths and needs):

Does your child currently attend daycare? Yes No (If no, skip to next question) Current daycare setting Daycare Name: Phone # Teacher/Staff Name: Describe current daily functioning in daycare setting (including strengths and needs):

5 CHILD’S MEDICAL & PHYSICAL HISTORY

Who is the child’s primary doctor? Phone # Who is the child’s primary dentist? Phone # When was your child last seen by a physician? For what reason? Child’s current height: weight: Is the child’s general physical health good? Yes No Serious and/or chronic illness now (or in past)? Are immunizations up to date? Yes No Has child had any history of seizures or head injury, serious injuries/accidents, or episodes with loss of consciousness Yes No If yes, please provide details: Has your child had any history of medical hospitalizations or surgeries? Yes No If yes, please provide details: Have you started toilet training? Yes No Please describe any toilet training concerns: Do you have any concerns about gender-inappropriate behavior? Yes No If yes, explain: Does your child use any non-psychiatric medications, including homeopathic, naturopathic or other alternative medicine for physical health? Yes No

If yes, please provide information on name of medication, condition being treated, prescribing provider, dose/schedule, and response/side effects:

Does your child have any pain issues or concerns? Yes No If yes, explain:

CHILD SOCIAL-BEHAVIORAL HISTORY Does your child have behavior problems at home? (please specify): Does your child have behavior problems at school/daycare/church/school? (please specify): Does your child have behavior problems in the community (e.g. grocery store, public places, etc; please specify):

Has your child been prescribed psychiatric medications for emotional or behavioral concerns? Yes No If yes, please provide information on name of medication, condition being treated, prescribing provider, dose/schedule, and response/side effects:

6 Please list all mental health or other treatment providers who have evaluated and/or provided treatment to your child in the past

Type of Service Service Provider/Address Dates Results

History of violence/grief and loss Has child been exposed to domestic violence? Yes No Has child been a witness to violence or traumatic death? Yes No Has child experienced death of parent/psychological parent? Yes No If yes to any of the above, please provide details: Child abuse/neglect history Has child had history of physical abuse sexual abuse persistent inadequate parenting or neglect?

Has abuse/neglect been documented by CPS/Legal System? Yes No If yes, what were the circumstances and outcome? Has the abuse history been previously addressed by a professional? Yes No If so, how? Does your child participate in any community activities (e.g. sports, boys & girls, church)? Yes No If yes, please list the activities/groups: Please describe forms of discipline which have been used in the home and their effectiveness:

Please list those qualities about your child that you consider to be strong positive points.

Please list those qualities about your child that you consider to be strong negative points.

Describe your child’s friendships (e.g. playmates come over, go to playmate’s house, etc):

Please make a brief statement about the relationship between patient and Mother/maternal caregiver: Father/paternal caregiver: Siblings: Ethnic/cultural identification of parent/child/extended family, including relevant beliefs about mental health and illness:

7 FAMILY MEDICAL HISTORY Please list any pertinent family medical history for

Adoptive/Preadoptive Family: not applicable

Please check any items that apply past or present for any member of the child’s biological/birth family Mother’s Father’s Condition/Circumstance Child Mother Father Sibling Family Family Mental Retardation Learning Disorder Attention Deficit Hyperactivity Seizures/Epilepsy Neurological Disorders Alcohol Abuse Drug Abuse Physical/Emotional Abuse Sexual Abuse Depression Bipolar Disorder Suicide Attempts Anxiety Disorders Separation Anxiety Specific Fears or Phobias Obsessive-Compulsive Disorder Panic Attacks Schizophrenia Visual Disability/Problems Deaf/Hard of Hearing Tics/Tourette’s Syndrome Chronic Illnesses Juvenile Delinquency Arrests/Incarceration Harassment by Peers Homelessness Teen Pregnancy School Suspension/Expulsion Special Education Birth Defects Miscarriages Other: FAMILY MEDICAL HISTORY Is there anything else you would like us to know about your child that we did not ask?