Child Biographical Information Form

Information Supplied By*
First Last
Relationship to Child*
Personal History
Child's Name*
First Last
Age*
Please enter a number from 1 to 17.
Gender*
- Male
- Female
Weight
Height
Eye Color*
Hair Color*
Race
Address*
Street Address Address Line 2 City State ZIP Code
Today's Date*
Date Format: MM slash DD slash YYYY
Date of Birth*
Home Phone*
Year in School*
Has the child been involved in previous counseling?*
- Yes
- No
If Yes, Please Describe:
Why is the child currently coming in to counseling?*
How long has this problem persisted?*
Under what conditions do the problems usually get worse?*
Under what conditions do the problems usually get better?*
Medical History
Physician's Name*
Physician's Address
Last Physical Exam
Results
List any major illnesses and/or operations
List any physical concerns presently occurring (e.g. high blood pressure, headaches, dizziness. etc.)
List any physical concerns (e.g. head trauma, seizures, etc.) experienced in the past
On average how many hours of sleep does the child receive?
Does the child have trouble falling asleep at night?*
- Yes
- No
If Yes, how long has this been a problem?
Describe the child's appetite (during the past week)
- poor appetite
- average appetite
- high appetite
What medications (and dosages) are being taken presently, and for what purpose?
Family History
Mother's Age*
If deceased, how old was the child when she passed away?
Father's Age*
If deceased, how old was the child when he passed away?
If parents are separated or divorced, how old was the child then?
Number of brother(s)*
Their ages
Number of sister(s)*
Their ages
Child number
In a family of _______ children.
Is the child adopted or raised with parents other than biological parents?*
- Yes
- No
Briefly describe the child's relationship with brothers and/or sisters (Biological siblings).
Briefly describe the child's relationship with brothers and/or sisters (Step and/or half siblings).
Briefly describe the child's relationship with brothers and/or sisters (Other).
What is the family relationship between the child and his/her custodial parents? (Check all which apply)*
- Single Parent Mother
- Single Parent Father
- Parents Unmarried
- Parents Married, Together
- Parents Divorced
- Parents Separated
- With Mother and Stepfather
- With Father and Stepmother
- Child Adopted
- Other (Please Describe In Next Field)
If Other, please describe.
Is there a history or recent occurrences of child abuse to this child?*
- Yes
- No
If Yes, which type(s) of abuse?
- Verbal
- Physical
- Sexual
Comments
Mother's Occupation
Father's Occupation
Briefly describe the style of parenting used in the household.
Developmental History
Briefly describe any problems in the child's mother's pregnancy and/or childbirth.
At what age did the child begin walking?
Comments
At what age did the child begin talking?
Comments
At what age was the child toilet trained?
Comments
List any drugs used by the mother or father at time of conception, or by mother during pregnancy.
Please rate your opinion of the child's social development (compared to others the same age).*
- Below Average
- About Average
- Above Average
Please rate your opinion of the child's physical development (compared to others the same age).*
- Below Average
- About Average
- Above Average
Please rate your opinion of the child's speech development (compared to others the same age).*
- Below Average
- About Average
- Above Average
Please rate your opinion of the child's intellectual development (compared to others the same age).*
- Below Average
- About Average
- Above Average
Please rate your opinion of the child's emotional development (compared to others the same age).*
- Below Average
- About Average
- Above Average
For each of the types of development in which you rated above as BELOW AVERAGE, please describe specific areas of concern the child has currently. Be specific.
List the child's three greatest strengths.
List the child's three greatest weaknesses or needed areas of improvement.
List the child's main difficulties at school.
List the child's main difficulties at home.
Briefly describe the child's friendships.
What report card grades does the child usually receive?*
Have these changed lately?*
- Yes
- No
If Yes, how?
Briefly describe the child's hobbies and interests.
Describe how the child is disciplined.
For what reasons is the child disciplined?
Behaviors Of Concern
Please check how often the following behaviors occur.
Loses temper easily*
- Never
- Rarely
- Sometimes
- Frequently
Argues with adults*
- Never
- Rarely
- Sometimes
- Frequently
Refuses adults' requests*
- Never
- Rarely
- Sometimes
- Frequently
Deliberately annoys people*
- Never
- Rarely
- Sometimes
- Frequently
Blames other for own mistakes*
- Never
- Rarely
- Sometimes
- Frequently
Easily annoyed by others*
- Never
- Rarely
- Sometimes
- Frequently
Angry / resentful*
- Never
- Rarely
- Sometimes
- Frequently
Spiteful / vindictive*
- Never
- Rarely
- Sometimes
- Frequently
Defiant*
- Never
- Rarely
- Sometimes
- Frequently
Bullies / teases others*
- Never
- Rarely
- Sometimes
- Frequently
Initiates fights*
- Never
- Rarely
- Sometimes
- Frequently
Uses a weapon*
- Never
- Rarely
- Sometimes
- Frequently
Physically cruel to people*
- Never
- Rarely
- Sometimes
- Frequently
Physically cruel to animals*
- Never
- Rarely
- Sometimes
- Frequently
Stealing*
- Never
- Rarely
- Sometimes
- Frequently
Forced sexual activity*
- Never
- Rarely
- Sometimes
- Frequently
Intentional arson*
- Never
- Rarely
- Sometimes
- Frequently
Burglary*
- Never
- Rarely
- Sometimes
- Frequently
"Cons" other people*
- Never
- Rarely
- Sometimes
- Frequently
Runs away from home*
- Never
- Rarely
- Sometimes
- Frequently
Truant at school*
- Never
- Rarely
- Sometimes
- Frequently
Doesn't pay attention to details*
- Never
- Rarely
- Sometimes
- Frequently
Several careless mistakes*
- Never
- Rarely
- Sometimes
- Frequently
Does not listen when spoken to*
- Never
- Rarely
- Sometimes
- Frequently
Doesn't finish chores/homework*
- Never
- Rarely
- Sometimes
- Frequently
Difficulty organizing tasks*
- Never
- Rarely
- Sometimes
- Frequently
Loses things*
- Never
- Rarely
- Sometimes
- Frequently
Easily distracted*
- Never
- Rarely
- Sometimes
- Frequently
Forgetful in daily activities*
- Never
- Rarely
- Sometimes
- Frequently
Fidgety / squirmy*
- Never
- Rarely
- Sometimes
- Frequently
Difficulty remaining seated*
- Never
- Rarely
- Sometimes
- Frequently
Runs / climbs around excessively*
- Never
- Rarely
- Sometimes
- Frequently
Difficulty playing quietly*
- Never
- Rarely
- Sometimes
- Frequently
Hyperactive*
- Never
- Rarely
- Sometimes
- Frequently
Difficulty awaiting turn*
- Never
- Rarely
- Sometimes
- Frequently
Interrupts others*
- Never
- Rarely
- Sometimes
- Frequently
Problems pronouncing words*
- Never
- Rarely
- Sometimes
- Frequently
Poor grades in school*
- Never
- Rarely
- Sometimes
- Frequently
Expelled from school*
- Never
- Rarely
- Sometimes
- Frequently
Drug abuse*
- Never
- Rarely
- Sometimes
- Frequently
Alcohol consumption*
- Never
- Rarely
- Sometimes
- Frequently
Depression*
- Never
- Rarely
- Sometimes
- Frequently
Shy / avoidant / withdrawn*
- Never
- Rarely
- Sometimes
- Frequently
Suicidal threats / attempts*
- Never
- Rarely
- Sometimes
- Frequently
Fatigued*
- Never
- Rarely
- Sometimes
- Frequently
Anxious / nervous*
- Never
- Rarely
- Sometimes
- Frequently
Excessive worrying*
- Never
- Rarely
- Sometimes
- Frequently
Sleep disturbance*
- Never
- Rarely
- Sometimes
- Frequently
Panic attacks*
- Never
- Rarely
- Sometimes
- Frequently
Mood shifts*
- Never
- Rarely
- Sometimes
- Frequently
For each of the behaviors noted on the previous page as occurring FREQUENTLY, or if it causes significant impairment, write a brief description of how it impacts the child's or other people's lives. Give examples if possible.
Briefly describe the child's ways of expressing ANGER.*
Briefly describe the child's ways of expressing HAPPINESS.*
Briefly describe the child's ways of expressing SADNESS.*
Briefly describe the child's ways of expressing ANXIETY.*
List the child's behaviors which you would like to see change.
Additional information you believe would be helpful:

Child Biographical Information Form

Personal History

Medical History

Family History

Developmental History

Behaviors Of Concern