Miki hawkins, lmft
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|  Yüklə 42.5 Kb.
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| 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?
________________________________________________________________________________________________________________________________________________________________________________________________________________________ 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? ________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________ 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?________________________________________________________
Hyperactivity?____________________________________________________________ Alcoholism?_____________________________________________________________ Substance Abuse?_________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ |