Ana səhifə

Miki hawkins, lmft


Yüklə 25.23 Kb.
tarix18.07.2016
ölçüsü25.23 Kb.
MIKI HAWKINS, LMFT

CHILD/ADOLESCENT EVALUATION


________________________________________________________________________NAME DATE
General History
A. Primary concern – generally _______________________________________________________________________________________________________________________________________________

Why treatment now? Teacher? Event? Grandma?

________________________________________________________________________________________________________________________________________________

General Major Concerns


_______________________________________________________________________

1. Who? ________________________________________________________________

2. Ages? ________________________________________________________________

3. Occupation?

________________________________________________________________________

C. Ask Parents individually - > Drugs? Alcohol? Law? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

D. How long married? Ist marriage? other kids? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

E. How is this _____ yr marriage going? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

F. Are you 2 in agreement on discipline? ________________________________________________________________________________________________________________________________________________________________________________________________________________________

G. Both see a problem? OR just Mom? Dad? _______________________________________________________________________________________________________________________________________________________________________________________________________

H. How is child’s behavior in the home?
Generally first, then specific.

________________________________________________________________________________________________________________________________________________________________________________________________________________________

How does the child follow the basic rules of the house? i.e. no eating in the kitchen?

________________________________________________________________________________________________________________________________________________________________________________________________________________________


How about moment to moment request, i.e. pick that up please?

________________________________________________________________________________________________________________________________________________


How responsible is the child for chores?

________________________________________________________________________________________________________________________________________________


Does he/she sass?___________________________________________________
Has he physically acted out towards you?

________________________________________________________________________________________________________________________________________________




  1. Child’s mood?

________________________________________________________________________________________________________________________________________________
J. What is it like to take the child out in public?

________________________________________________________________________________________________________________________________________________


K. How does child entertain self?

________________________________________________________________________________________________________________________________________________


L. Are tasks completed once started?__________________________________________
M. Can you read a book to the child?_________________________________________
N. Is the child organized?_________________________________________________
O. Does Child have fears?__________________________________________________
P. Child’s Eating Patterns?

________________________________________________________________________________________________________________________________________________


Q. Child’s sleep patterns?

________________________________________________________________________________________________________________________________________________


R. How Does the child behave outside of the home?

________________________________________________________________________________________________________________________________________________


S. How is child getting along in the neighborhood?

________________________________________________________________________________________________________________________________________________


T. What are the ages of playmates?

________________________________________________________________________________________________________________________________________________




School

U. In Preschool/Elem/Jr. Sr.? _________________________________________________

V. What kind of sports?


________________________________________________________________________

________________________________________________________________________


W. What is the theme of what the teacher says?

________________________________________________________________________________________________________________________________________________


X. What is currently going on in school?
1. Academically? ________________________________________________________________________________________________________________________________________________________________________________________________________________________
2. Behaviorally?

________________________________________________________________________________________________________________________________________________


3. Retained or socially promoted?

________________________________________________________________________________________________________________________________________________

Why? ________________________________________________________________________

4. Special Ed?____________________________________________________________

Nature of Program?

________________________________________________________________________________________________________________________________________________


Y. Prenatal
Pregnancy planned?_______________________________________________________
Problems during gestation?_________________________________________________
Complications?__________________________________________________________
Falls?__________________________________________________________________
Accidents?_____________________________________________________________
Substantial Stress?________________________________________________________
Smoking?_______________________________________________________________

Drinking?_______________________________________________________________


Drugs?_________________________________________________________________
Z. Birth Complications?

________________________________________________________________________________________________________________________________________________


Early developmental History.
Eat?____________________________________________________________________________________________________________________________________________

Sleep?__________________________________________________________________________________________________________________________________________

Difficult Child?___________________________________________________________

Colicky?________________________________________________________________


Difficult nursing?_________________________________________________________
Problems sleeping thru night after 6 months?____________________________________
Developmental milestones.

Crawling?______________________________________________________________

Walking?______________________________________________________________

Talking?_______________________________________________________________


Major Illnesses

Hospitalized?___________________________________________________________


Falls?_________________________________________________________________
Seizures?______________________________________________________________
Parent’s History
How much parental education?____________________________________________
Learning Problems?_____________________________________________________
Previous mental disorders?_________________________________________________

________________________________________________________________________________________________________________________________________________


History on either side of family of:

Learning disability? ________________________________________________________________________________________________________________________________________________

Mental retardation?________________________________________________________
Mental Illness? ________________________________________________________________________________________________________________________________________________

Hyperactivity?____________________________________________________________


Alcoholism?_____________________________________________________________
Substance Abuse?_________________________________________________________

________________________________________________________________________



________________________________________________________________________


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©atelim.com 2016
rəhbərliyinə müraciət