Oralndo Behavioral Health

ORALNDO BEHAVIORAL HEALTH CHILDREN’S HISTORY FORM

Name: ______Date: ______

DOB: ______/______/______AGE: ______DATE SEEN: ______/______/______Month Day Year Month Day Year

Informant: ______Relationship To Child: ______

What Made You Seek Help At This Time?: ______

Provide A Brief Description Of Major Areas Of Concern (Including duration and how you have handled them): ______

Has Your Child Had Any Previous Psychiatric/Psychological Evaluations/Treatments? (Please elaborate)

Date Treating Professional Reason Outcome ______Developmental Milestones (In months)

Sat alone: ______Walked: ______Talked in sentences: ______

Weaned: ______Fed self: ______Tied own shoes: ______

Toilet Training (Ease or difficulty; any wetting or soiling afterward): ______Who Does Your Child Live With/ Who Has Everyday Custody Of your Child?: ______

Academic History (Please provide grade level, name of the school and any pertinent school history): ______

Past And Current Medical History/Meds: ______

Please Comment On Any Areas Of Concern Not Covered Above: ______

______Signature of person completing form Date

______Clinician’s signature Date