Part IV: Child’s Evaluation and Treatment History List in chronological any evaluation done for any developmental, behavioral, or learning problems. Clinic / Name & Profession Type of Results / Institution Evaluation Recommendations List in chronological order any outpatient help and/or hospitalization for any psychiatric or psychological problems. Dates Clinic / Name & Profession Reason for Treatment Frequency Institution Therapy Type (from…to…) (e.g., psychologist, (e.g., (e.g., talk, psychiatrist, counselor) 1x/week, CBT, medication) inpatient) Part V: Family History Please note whether each relative has any of the following and whether they sought treatment for each. Anxiety / Alcohol / Drug Psychosis / Attention / Learning Health Problems Depression / Schizophrenia Behavior / Disabilities / Bipolar Conduct Problem Problems Maternal Grandmother Grandfather Mother Aunt Uncle Paternal Grandmother Grandfather Father Aunt Uncle Siblings Brother Sister Part V: Health and Developmental History
Part IV: Child’s Evaluation and Treatment History List in chronological any evaluation done for any developmental, behavioral, or learning problems. Clinic / Institution Name & Profession Type of Evaluation Results / Recommendations List in chronological order any outpatient help and/or hospitalization for any psychiatric or psychological problems. Dates (from…to…) Clinic / Institution Name & Profession (e.g., psychologist, psychiatrist, counselor) Reason for Therapy Treatment Type (e.g., talk, CBT, medication) Frequency (e.g., 1x/week, inpatient) Part V: Family History Please note whether each relative has any of the following and whether they sought treatment for each. Anxiety / Depression / Bipolar Alcohol / Drug Psychosis / Schizophrenia Attention / Behavior / Conduct Problem Learning Disabilities / Problems Health Problems Maternal Grandmother Grandfather Mother Aunt Uncle Paternal Grandmother Grandfather Father Aunt Uncle Siblings Brother Sister Part V: Health and Developmental History
child_adolescent_intake_information_form___age_1-17_.docx