Create Child and Adolescent Form (Ages 5-18)

Please complete the following information so that we can better understand your concerns and the reasons you are seeking psychological or psychoeducational testing. This will help us determine the type of evaluation needed. Some questions may not apply and it is fine to just answer the question "No" or enter NA for " Not Applicable." The information in this form is guaranteed to be kept confidential and secure. Please remember to click "Submit" when you have finished.
 
    Basic Information
  Child or Adolescent's First Name: *
Child or Adolescent's Last Name: *
Child or Adolescent's Gender: *
Child or Adolescent's Birth Date: *
Child or Adolescent's Grade: *
Child or Adolescent's Name of School:
Name of person completing this form: *
Relation to child/adolescent
(mother, father, guardian, other):
*
Address: *
City: *
State: *  
ZIP: *
Phone: *
Alternate Phone:
Email: *
Preferred Method of Contact: *
Emergency Contact (Email, Phone, etc): *
Who referred you to CReATE or how did you hear about us? *
Do you want us to have contact with your referral source? *
If yes, Name, phone number, and email of referral source:
Referral Name:
Referral Phone:
Referral Email:
Briefly describe the reason for referral, your concerns, or a little about your child/adolescent's current difficulties:

    Pregnancy/Developmental History:
Was your child/adolescent adopted? If yes, please indicate at what age and any special circumstances (e.g. foreign or domestic adoption, conditions of orphanage, suspected abuse or neglect, etc.):
Were there any illnesses or complications with the mother while pregnant with this child? If yes, please explain:
Was the child born full-term? If no, how many weeks gestation and weight at birth?
Describe any problems related to the child's birth:
Describe any concerns or problems regarding infancy or early childhood development:

    Academic Information:
Do you have concerns about your child or adolescent's academic progress? If yes, please describe briefly:
Has your child/adolescent ever received special education services or been evaluated by the school system? (i.e. to determine eligibility for IEP, 504 or special services)? If yes, what was the outcome?
Have you ever sought specialized tutoring services or other services such as speech-language therapy or occupational therapy services for your child/adolescent? If yes, please describe briefly:
Has your child/adolescent been previously diagnosed with learning difficulties (e.g. ADHD, LD). If yes, by whom?
Has your child/adolescent been tested for mental health or learning concerns previously? If yes, when was the testing done and by whom (i.e. school system, private evaluator, hospital)?
Names of schools and years attended:  
Elementary:
Middle:
High School:

    Behavioral Concerns
Are you concerned about your child or adolescent’s behavior at home or in school or both? If yes, Please describe briefly:
Briefly describe any suspensions, expulsions, or disciplinary actions in school:
Briefly describe any behavioral concerns, including violent or aggressive behavior, involvement with legal authorities, or history of running away:
Please describe any history of substance abuse, including frequency/severity, if known:

    Emotional Concerns
Are you concerned about your child or adolescent’s emotional status or self-esteem? If yes, please describe briefly:
Are you concerned about your child or adolescent’s mood or level of anxiety? If yes, please describe:
Has your child/adolescent been previously diagnosed with any emotional problems (e.g. Depression, Anxiety, Social Phobia, Panic Disorder, etc.)? If yes, please describe:
Describe any major traumatic events or changes in your child/adolescent’s life (e.g. abuse, illness, death, difficult moves, difficult transitions to new schools, etc.)
Has your child/adolescent ever been hospitalized for psychiatric/psychological reasons? If yes, please describe circumstances, dates, and diagnoses:
Has your child/adolescent ever expressed suicidal ideation or engaged in any self-harm? If yes, please describe circumstances and dates:

    Medical Concerns
Does your child or adolescent have any chronic or recent medical concerns? (e.g. chronic ear infections when younger, PE tubes, asthma, allergies, cerebral palsy, diabetes, food allergies, etc.) Please describe history and treatment:
Has your child/adolescent experienced any concussions or head injuries or had numerous visits to the ER? If yes, please describe:
Has your child/adolescent had any surgeries? If yes, please describe:
Is your child or adolescent currently taking any medications? If so, please list and describe any side effects:
Name of Primary Care Physician:
Approximate date of last vision/hearing screening and indicate if results were normal or abnormal:

     Treatment History
Please describe any prior or current treatments, interventions, or therapies (outpatient therapy, psychiatric monitoring, IOP, residential treatment, medication, school-based interventions, etc.):
Name of Psychiatrist, Developmental Pediatrician, or Therapist (if applicable):

    Family Information
Does your child/adolescent live with both parents? If no, briefly describe custody and living arrangements:
Is any legal action currently underway in this family? If yes, please explain:
If parents are divorce/separated, is the other parent aware that you are seeking an evaluation for your child?:
Father's Name and Occupation (optional):
Mother's Name and Occupation (optional):
Stepfather's Name and Occupation (optional):
Stepmother's Name and Occupation (optional):
Siblings (number of siblings, names and ages):
Briefly describe any significant family information, such as parent-child conflict, marital discord, or significant discord between family members:
Has your child or adolescent recently moved or changed schools? (If so, describe):
Is there a family history of learning or mental health concerns (e.g. ADHD, dyslexia, depression, OCD, etc)? If so, who?:
Please list your child/adolescent's strengths, hobbies, interests, achievements, or positive traits:

Please scan through the behaviors or concerns listed below and indicate if you have noticed that specific problem with your child or adolescent. Please check all that apply. If your child is older, please check items that were noticed in their earlier childhood. There are also a few items specific for adolescents.

Reading
difficulty learning the alphabet difficulty learning to blend sounds
had more difficulty learning to read than expected based on verbal abilities unable to read smoothly
poor tracking mispronunciations
doesn’t understand what is read reads slowly
reverses letters tires easily when reading
resists reading poor recall
Additional items for adolescents:
difficulty completing longer reading passages difficulty comprehending longer reading passages
does not grasp the main idea recall of reading passages is poor

Math
poor arithmetic calculation poor sequential procession (doing things in order)
poor understanding of math concepts many careless errors
difficulty learning basic math facts resists math
tires easily when working math difficulty holding numbers in head to work problems
Additional items for adolescents:
difficulty understand more complex math of middle school or high school difficulty with geometry and spatial math specifically
does not show his/her work recall of learned math concepts is poor

Writing
difficulty with early handwriting continued poor handwriting
poor spelling letter reversals
difficulty getting thoughts on paper resists writing
writing is laborious, arduous writing below expectation of verbal abilities
difficulty organizing sentences/paragraphs poor punctuation, capitalization
poor use of grammar in writing often does not complete writing assignments
Additional items for adolescents:
difficulty getting started on essays or papers difficulty organizing thoughts in writing
does not know how to keyboard efficiently difficulty communicating effectively through writing

Motor
difficulty learning to tie shoes difficulty learning to ride a bike
poor fine motor skills poor visual-spatial skills (drawing, copying figures)
poor sense of direction poor balance or coordination
resists sports resists physical activity

Language
articulation problems word retrieval problems
gets tongue-tied difficulty expressing him/herself
has difficulty understanding what is said has difficulty following multi-step directions
seems to have difficulty listening with distractions    

Social
not invited back for playdates or birthday parties prefers one or two close friends to groups
difficulty initiating social interactions difficulty sustaining social interactions
is bullied or teased bullies or teases others
does not read social cues well feels rejected by peers
feels picked on by peers does not seem to get jokes
timing seems a little off acts awkward around peers
difficulty establishing or maintaining friendships difficulty understanding the perspectives of others

Other
talks incessantly becomes easily over-stimulated
does not like tags in clothing is easily startled
does not like certain textures of clothing very picky about food
has muscle or verbal tics has difficulty with transitions
has only a few, narrow interests only wants to talk about one or two things
becomes upset if routine is changed is inflexible, stubborn
over sensitive or under sensitive to sensory input (auditory tactile) poor motor coordination
has specific phobias enuresis (daytime or nighttime bedwetting)
  (List Phobias:)
   

Behavior (Current)
Impulsive Too physically active
Hard time sitting still for long Concerns about behavior in school
Difficulty following directions Defiant or oppositional
Difficulty organizing belongings Forgetful
Careless mistakes Avoids homework
Can't sustain attention for long Does not listen when spoken to
Loses things often Is easily distracted
Fidgety or restless Blurts out answers in class
Has difficulty waiting his/her turn Interrupts others or is intrusive
Difficulty with sleep initiation Difficulty with sleep persistence
Difficulty with early morning awakening Night terrors
Sleep walking    

Developmental: Although you may not remember your child or adolescent's detailed developmental history, please scan through the following list and check if you remember hearing anyone describe that you had any of the following developmental concerns during infancy or toddlerhood through age 4 or 5. If you do not know, you can leave this section blank.

Expressive language delayed:
No babbling by 9 months No single words by one year
No phrase speech by 18 months Only a few words by age 2
Repeated or echoed phrases without communicative intent (echolalia) Articulation poor or very difficult for others to understand
Initial language delayed but then progressed rapidly by age 3.5    

Receptive language delayed:
Did not respond to simple requests (e.g. "Come here") by 1 year Did not wave "bye bye" or clap hands by 1 year
Did not attempt to communicate by pointing by 14 months Did not understand simple words (e.g. "ball", "snack") by 18 months
Did not understand simple commands (e.g. "Get your shoes") by age 2 Did not use gestures or pointing to communicate
Did not look at people when they were talking Poor eye contact in general

Motor skills:
Did not sit up independently by 9 months Did not crawl or move around freely by 1 year
Did not walk alone by 18 months Walked on tip toes past age 2
Unusual posturing or hand movements Resisted coloring or drawing in preschool
Did not learn to tie shoes by age 5-6 Did not learn to ride a bike by age 5-6
Clumsy, awkward when running/jumping    

Social/Emotional:
No social smile by 6 months Not cuddly as an infant
Had colic or fussy as baby Did not respond to name by 9 months
Did not look at people when they talked to him/her by 1 year Did not enjoy simple games such as peek-a-boo ir pat-a-cake by 1 year
Did not engage in imaginative play by age 3 Did not engage in cooperative imaginary play with peers by age 3-4
Lined up toys or played with parts of toys (e.g. spinning wheels) Preferred to play by self
Preferred to play with younger children Severe tantrums out of proportion for developmental age
Difficulty self-soothing    

Behavior:
Impulsive Very active for age
Ran about or climbed in situations where that was inappropriate Hard time sitting still for long
Could not sit through a meal by age 4 Concerns about behavior in preschool
Engaged in biting behavior in preschool Difficulty following directions
More defiant than typical for preschool years Morning, afternoon, bedtime routines difficult
Difficulty with sleep initiation Difficulty with early morning awakening
Night terrors Sleep walking

Adaptive Behavior:
Did not drink from cup by 12 months Did not feed self by 18 months
Could not dress self by age 4 Not potty trained by age 3 during day
Bed wetting at night past age 4 Sleep walking
 
*You will have a chance to elaborate on any of the above checked items when you talk with the psychologist.
However, if you want to briefly explain any items, you can do so here:



Please take a moment to review your answers before submitting this form. Make sure all fields marked with a (*) are completed and the information you provide is as accurate as possible. Only press the submit button once. Be patient as occasionally it takes a moment to submit the form. The information submitted in this form is guaranteed to be kept confidential and secure.