This document contains a comprehensive assessment for a client, including sections on demographic information, pregnancy and birth history, developmental history, medical history, educational history, family history, mental status exam, and risk assessment. Key details provided include the client's date of birth, presenting problems, complications during pregnancy and birth, developmental milestones, medical issues, academic performance, family structure and relationships, substance use, and suicidal/homicidal risk factors. The assessment aims to gather a holistic understanding of the client to inform treatment.

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Parent Information
Legal Guardian (ifother than parent): Phone: Email:
Address: City: State: Zip:
Parent Name: Phone: Email:
Address: City: State: Zip:
Other Parent: Phone: Email:
Address: City: State: Zip:
Other parent’s level of involvement/role in child’s life:
Client: Phone: Email:
Address: City: State: Zip:
Demographics
Place of Birth: Child’s Spirituality:
State: Denomination/Belief System:
County: Ethnicity:
City: Race:
Birth Name: Language Preference:
Client’s Main Presenting Problems Why now? Include clientreportas well as teacher, parent& clinician observation/testing.Pleasebe specific
Pregnancy with Client
Was this child a planned pregnancy? Yes No Was the mother under a doctor’s care? Yes No
Previous miscarriages/pregnancies:
Complications
Difficulty conceiving Toxemia Abnormal weight gain
Measles Excessive vomiting German measles
Excessive swelling Emotional problems Vaginal bleeding
Flu Anemia High blood pressure
Rh incompatibility Injury Hospitalization
X-rays Other:
Medications used during pregnancy:
Alcohol consumed during pregnancy:
Cigarettes smoked during pregnancy:
Addictions/ other drugs used during pregnancy:
Client’s Birth
At child’s birth, what was the mother’s age? At child’s birth, what was the father’s age?
First child: Mother’s age at birth of first child:
Was this child born in a hospital? Yes No If no, where?
Length of pregnancy: Birth weight:
Length of labor: Apgar score:
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Report Date:
Client Name (last, first):
DOB: Gender: Click here Admit Date:
IEP Date: Semi-annual Tx Plan Date:
Program: School:
Therapist:
Teacher:

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Child’s condition at birth:
Mother’s condition at birth of child:
Complications
Forceps used Breech birth Labor induced Caesarean delivery
Other delivery complications:
Incubator: Yes No If yes, how long?
Jaundiced: Bilirubin lights? Yes No If yes, how long?
Breathing problems right after birth? Yes No If yes, how long?
Supplemental oxygen: Yes No If yes, how long?
Was anesthesia used during delivery? Yes No If yes, how long?
Length of stay in hospital: Mother Child
Other birth complications:
Developmental History
At what age did the child:
First turn over: First sit alone: First crawl: First stand alone:
First walk alone: First walk up stairs: First walk down stairs: First respond to sound:
Understand first words: Speak first words: Speak in sentences:
At what age was the child toilet trained? Days: Nights:
Did bed-wetting recur after toilet training? Yes No If yes, at what age?
Did bed-soiling recur after toilet training? Yes No If yes, at what age?
Were there any medical reasons for the bed-wetting/soiling? If yes, please describe:
Impressions:
Has this child ever experiences any of the following problems? If so, please describe.
Walking difficulty: Yes No If yes, age & description:
Unclear speech: Yes No If yes, age & description:
Feeding problem: Yes No If yes, age & description:
Under-weight problem: Yes No If yes, age & description:
Over-weight problem: Yes No If yes, age & description:
Colic: Yes No If yes, age & description:
Sleep problems: Yes No If yes, age & description:
Nightmares: Yes No If yes, age & description:
Eating disorder: Yes No If yes, age & description:
Difficulty learning to ride a bike: Yes No If yes, age & description:
During the first 4 years of the child’s life, were there any problems in the following areas? If so, please describe.
Eating: Yes No If yes, please describe:
Motor skills: Yes No If yes, please describe:
Sleeping too much: Yes No If yes, please describe:
Sleeping too little: Yes No If yes, please describe:
Temper tantrums: Yes No If yes, please describe:
Failure to thrive: Yes No If yes, please describe:
Separating from parent/s: Yes No If yes, please describe:
Excessive crying: Yes No If yes, please describe:
Which hand does this child use for drawing? Right Left
Which hand does this child use for eating? Right Left
Has the child been forced to change writing hand? Yes No
Medical History
Childhood Illnesses & Injuries

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Measles: Yes No Age: Mumps: Yes No Age: Chicken pox: Yes No Age:
German measles: Yes No Age: TB: Yes No Age: Whooping cough: Yes No Age:
Scarlet fever: Yes No Age: Diphtheria: Yes No Age: Encephalitis: Yes No Age:
Rheumatic fever: Yes No Age: Anemia: Yes No Age: Fever 104 + : Yes No Age:
Other illnesses:
Head injury: Yes No Age & description:
Sustained high fever: Yes No Age & description:
Operations: Yes No Age & description:
Has the child ever been on long-term medication (more than 6 months)? Yes No Age & description:
Neurological Problems
Seizures/convulsions: Yes No Age & description:
Bites nails: Yes No Age & description:
Sucks thumb: Yes No Age & description:
Grinds teeth: Yes No Age & description:
Has tics/twitches: Yes No Age & description:
Bangs head: Yes No Age & description:
Rocks back & forth: Yes No Age & description:
Allergies
Allergies to medicine: Yes No Describe:
Allergies to food: Yes No Describe:
Other allergies: Yes No Describe:
Hearing
Ear infections: Yes No Age & description:
Hearing problems: Yes No Age & description:
Ear tubes: Yes No Age & description:
Date of most recent hearing exam:
Vision
Vision problems: Yes No Describe:
Glasses or contacts: Yes No Describe:
Date of most recent vision exam:
Sleep Habits
How many of hours of sleep per night on average:
What time is bedtime? When actually sleeping? Morning wake up time?
Do these times change? Yes No Describe:
Insomnia? Yes No Describe frequency & duration:
Nightmares? Yes No Describe frequency and content:
Impressions:
Eating Habits
Meals: How often: Typical foods eaten & how much:
Breakfast /week
Lunch /week
Dinner /week
Snack /week
Describe any foods that are avoided & why:
Impressions:
Medical Care
Child’s physician’s name: Date of last physical:
Frequency of visits: Physician’s phone:
Current medications? Yes No

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Medication: Dose & time: Reason:
Medication: Dose & time: Reason:
Medication: Dose & time: Reason:
Medication: Dose & time: Reason:
Dental Care
Child’s dentist name: Date of last visit:
Frequency of visits: Dentist’s phone:
Educational History
Preschool
Academic strengths:
Does or did the child attend preschool? Yes No At what age:
Were there any behavioral or academic problems in preschool? Yes No Describe:
Does or did the child attend kindergarten? Yes No At what age:
Were there any behavioral or academic problems in kindergarten? Yes No Describe:
Elementary School
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Years: School &lLocation: Reason for leaving:
Middle School
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
High School
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Years: School & location: Reason for leaving:
Has the child had any of these experiences in school?
Been retained a grade? Yes No If yes, describe:
Skipped a grade? Yes No If yes, describe:
Difficulty with math? Yes No If yes, describe:
Difficulty with reading? Yes No If yes, describe:
Difficulty with writing? Yes No If yes, describe:
Poor grades? Yes No If yes, describe:
Been placed in a gifted program? Yes No If yes, describe:
Been tested for special education? Yes No If yes, describe:
Currently in special education? Yes No If yes, describe:
-If yes, what type of class & hours per day:
-Under what classification? LD SED OHI Speech/language
Is absent from school frequently? Yes No If yes, frequency and why:
Has been suspended from school? Yes No If yes, why:
Social Relations
Does child play well or interact well with others? Yes No If no, describe:
Prefer playing with younger children? Yes No If yes, describe:
Prefer playing with older children? Yes No If yes, describe:
Socialize with youth of similar age? Yes No If no, describe:

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Have difficulty with making friends? Yes No If yes, describe:
Fights frequently with peers? Yes No If yes, describe:
Prefer to play alone? Yes No If yes, describe:
Prefers to be alone or isolates from family, friends, or peers? Yes No If yes, describe:
Are there children in the neighborhood with whom this child could play? Yes No If no, describe:
What role does this child take in peer group games? Leader Follower Aggressor Other:
Does this child show affection easily? Yes No Describe:
Does this child strike out at family? Yes No Parents Siblings
Describe this child’s personality:
Family History
Discipline
Who has administered discipline to this child (as an infant, toddler, etc.)?
Who is currently administering discipline to this child?
What approach was used (as an infant, toddler, etc.)?
What approach is currently being used?
How has the child’s aggressive behaviors been dealt with (as an infant, toddler, etc.)?
How is the child’s aggressive behavior currently being dealt with?
What is done when the child has not follow directions previously (as an infant, toddler, etc.)?
What is currently done when the child does not follow directions?
If applicable, have the primary caretakers always agreed on ways to discipline the child (as an infant, toddler, etc.)? Yes No
Describe:
If applicable, do the primary caretakers currently agree on ways to discipline the child? Yes No
Describe:
What do the primary caretaker/s enjoy most about being with their child?
What do the primary caretaker/s least enjoy about being with their child?
History of Primary Caretakers
Length of time the child’s biological parents dated:
Married/co-habitation events :
Separation/divorce events:
Subsequent Relationships/Marriages
To whom: Child’s ages: Bx difficulties?: Yes No Describe:
To whom: Child’s ages: Bx difficulties?: Yes No Describe:
To whom: Child’s ages: Bx difficulties?: Yes No Describe:
To whom: Child’s ages: Bx difficulties?: Yes No Describe:
Siblings
Name: DOB/age: Bx difficulties?: Yes No Describe:
Name: DOB/age: Bx difficulties?: Yes No Describe:
Name: DOB/age: Bx difficulties?: Yes No Describe:
Name: DOB/age: Bx difficulties?: Yes No Describe:
Name: DOB/age: Bx difficulties?: Yes No Describe:
Name: DOB/age: Bx difficulties?: Yes No Describe:
Name: DOB/age: Bx difficulties?: Yes No Describe:
Losses (family members, friends, pets, etc)
Name: Child’s age: Child’s response:
Name: Child’s age: Child’s response:
Name: Child’s age: Child’s response:
Name: Child’s age: Child’s response:
Name: Child’s age: Child’s response:
Family Moves

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Childs age: Reason: Bx difficulties?: Yes No Describe:
Childs age: Reason: Bx difficulties?: Yes No Describe:
Childs age: Reason: Bx difficulties?: Yes No Describe:
Childs age: Reason: Bx difficulties?: Yes No Describe:
Childs age: Reason: Bx difficulties?: Yes No Describe:
Childs age: Reason: Bx difficulties?: Yes No Describe:
Significant others (aunt, uncle, grandparent, stepparent, family friend, mentor, etc.) for the child?
Name: Quality of relationship: Frequency of contact:
Name: Quality of relationship: Frequency of contact:
Name: Quality of relationship: Frequency of contact:
Name: Quality of relationship: Frequency of contact:
Name: Quality of relationship: Frequency of contact:
Family & Extended Family Health Issues
Cancer: Autism:
Cystic fibrosis: Schizophrenia:
Diabetes: Homelessness:
Migraine headaches: Depression:
Multiple sclerosis: Severe mood swings:
Thyroid problems: Rages:
Physical handicap: Suicide/attempts:
Alzheimer’s: Homicide/attempts:
Muscular dystrophy: Spending sprees:
Sickle-cell anemia: Facial Tics:
Tay-Sachs disease: Phobias:
Tourette’s syndrome: Psychiatric hospitalizations:
Birth defects: Incarceration:
Cerebral palsy: Reading problems:
Alcohol/drug abuse: Other learning problems:
History of Physical abuse: Speech/language problem:
Behavioral problems: Food allergies:
Mental retardation: Severe injury:
Genetic disorders: Highly creative/artistic:
Seizures/epilepsy: Criminal activity:
Mental illness: Other:
Risk Assessment
Substance Use/Abuse
Is client currently using any substances? Yes No
Substance: Amount & Frequency:
Interfering with
Functioning?
Client self-report of drug or
alcohol related problems:
Alcohol Yes No Denies problems Admits
Marijuana Yes No Denies problems Admits
Meth Yes No Denies problems Admits
Cocaine Yes No Denies problems Admits
Crack Yes No Denies problems Admits
Heroin Yes No Denies problems Admits
Rx meds: Yes No Denies problems Admits
Other: Yes No Denies problems Admits
History of use/abuse:

7. 7
History of Suicidal/Homicidal Ideation or Behavior
Suicidal Ideation: Homicidal Ideation:
Passive “wish to escape” Yes No Homicidal plan Yes No
Active “overt wish to die” Yes No Homicidal intent Yes No
Realistic plan Yes No Threatening behavior Yes No
Intent Yes No Assaultive behavior Yes No
Means Yes No Access to weapons/firearms Yes No
History of prior attempts? Yes No History of prior attempts? Yes No
Medical interventions? Yes No Police involvement? Yes No
Family history or attempts? Yes No Family history of homicidality? Yes No
Describe history of prior attempts (exactcircumstances, nature and lethality ofattempts, and method used to attempt(gun, knife/razor, drugs,alcohol,meds,etc.).Was
planning involved or was itan impulsive act? Did the clientattemptto seek help? Were substancesinvolved? Did client experienceany regretthatthe attemptfailed?):
Current Risk
Suicidal Ideation: Homicidal Ideation:
Passive “wish to escape” Yes No Homicidal plan Yes No
Active “overt wish to die” Yes No Homicidal intent Yes No
Realistic plan Yes No Threatening behavior Yes No
Intent Yes No Assaultive behavior Yes No
Means Yes No Access to weapons/firearms Yes No
Describe your initial plan for providing for the client’s/other’s safety given the risks:
Mental Status Exam
0 = No Problem/Normal, 1 = Mild Problem, 2 = Moderate Problem, 3 = Severe Problem
APPEARANCE 0 1 2 3 AFFECT 0 1 2 3
Unkempt, disheveled Labile
Clothing: dirty, atypical Blunted, dull, flat
Body odor Restricted range
Hair: dirty, un-styled, atypical Anxious
Skin: dirty, sores, atypical Depressed, sadness
Odd physical characteristics Irritable
Appears unhealthy Anger, hostility
Other: Euphoria, elation
EYE CONTACT 0 1 2 3 Alexithymic
Good Incongruent with context
Avoidant Incongruent with thought
Intense/unwavering Other:
None PERCEPTION 0 1 2 3
Other: Illusions
POSTURE 0 1 2 3 Auditory hallucinations
Slumped Visual hallucinations
Rigid, tense Tactile hallucinations
Other: Olfactory hallucinations
MOTOR ACTIVITY 0 1 2 3 Other:
Accelerated, quick COGNITIVE FUNCTIONING 0 1 2 3
Decreased, slowed Alertness
Restlessness, fidgety Attention span, distractibility
Atypical, unusual Short-term memory
Other: Long –term memory

8. 8
SPEECH 0 1 2 3 Abstract reasoning
Pressured (fast) General fund of knowledge
Slow Other:
Loud JUDGMENT 0 1 2 3
Soft-spoken Poor decision making
Mute Impulsivity
Impoverished Other:
Monotone THOUGHT CONTENT/FORMATION 0 1 2 3
Profanity Delusions
Confabulation Loose associations
Slurred, stuttering, mumbled Incoherent
Other: Depersonalization
ATTITUDE/BEHAVIOR 0 1 2 3 Blocking
Domineering, controlling Tangential
Submissive, dependant Circumstantial
Hostile, challenging, annoyed Poverty of thought
Guarded, suspicious Overvalues ideas
Uncooperative Goal directedness
Distant, withdrawn Obsessions/compulsions
Overly dramatic Phobic
Shy, cautious Other:
Childlike DANGEROUSNESS 0 1 2 3
Other: Homicidal ideation
INSIGHT 0 1 2 3 Suicidal ideation
Denial
Blames others
Slight awareness SENSORIUM Y N
Blames self Time
Intellectual insight only Place
Emotional & intellectual insight Person
Ability to make use of therapy Situation
Comments: Comments:
Trauma History
Parent was reminded of the limits of confidentiality and that answering “Yes” to any of these questions will result in the clinician contacting CPS.
Client was reminded of the limits of confidentiality and that answering “Yes” to any of these questions will result in the clinician contacting CPS.
Has the client ever experienced physical, sexual or emotional abuse? Yes No
Has the client ever experienced neglect? Yes No
1 Age: CPS Involvement at the time? Yes No
If so, please describe what happened (who, what, where, when):
How did the client’s behaviors change in response to the experience?
Please describe any services the child received because of this experience:
2 Age: CPS Involvement at the time? Yes No
If so, please describe what happened (who, what, where, when):
How did the client’s behaviors change in response to the experience?
Please describe any services the child received because of this experience:
3 Age: CPS Involvement at the time? Yes No
If so, please describe what happened (who, what, where, when):
How did the client’s behaviors change in response to the experience?
Please describe any services the child received because of this experience:

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4 Age: CPS Involvement at the time? Yes No
If so, please describe what happened (who, what, where, when):
How did the client’s behaviors change in response to the experience?
Please describe any services the child received because of this experience:
5 Describe any additional traumatic events in the client’s life:
CPS Reporting for Current Disclosures (MANDATORY)
Clinician filed a report with CPS and a copy of the report was filed in client file? Yes No No abuse/neglect reported
Date: Time: Person contacted at CPS:
Mental Health Services History
Has the client ever had psychological counseling or therapy? Yes No
1 Age: Type: Reason:
Outcome:
What was helpful?
What wasn’t helpful, if anything:
2 Age: Type: Reason:
Outcome:
What was helpful?
What wasn’t helpful, if anything:
3 Age: Type: Reason:
Outcome:
What was helpful?
What wasn’t helpful, if anything:
4 Age: Type: Reason:
Outcome:
What was helpful?
What wasn’t helpful, if anything:
5 Describe any additional therapeutic services:
Testing/Evaluations
Has the client ever had a neurological/neuropsychological exam? Yes No
Name of Physician/Psychologist: Phone:
Location:
Reason:
When:
Has the client ever had a psychological or psychiatric exam? Yes No
Name of Psychiatrist/Psychologist: Phone:
Location:
Reason:
When:
CPS Involvement
Has the client ever been involved in a Child Protective Services Investigation? Yes No
If yes, please describe:
Psychiatric Medications
Has the client ever been prescribed a psychiatric medication? Yes No
Has the parent ever declined to administer the medication? Yes No Reason:
List of prescribed medications: Dosage range: Time(s) of day: Result:
1.
2.
3.
4.
5.

10. 10
Client’s Main Presenting Problems/Symptoms (Include clientreportas well as teacher, parent& clinician observation/testing.Please be specific.)
Client’s Strengths & Interests
Diversity Considerations (Include if clientor family member’slegal status is an issue)
Medical Rule-Out for Current Symptoms
Has a physician ruled-out a medical basis for the client’s symptoms? Yes No Date of rule-out:
If no, clinician referred family/client to their physician for this purpose. Yes No Date referred:
Case Formulation (Given the client’s history,as well as their signs, symptomsand presenting problems,how do youconceptualizetheir currentpresentation? Whatis your
hypothesis aboutthe cause and nature ofthe presenting problems? Whatwill your treatmentapproachbe in addressing the client’s needs?)
DSM-5 Diagnosis: Clinical Disorder(s) and other conditions that may be a focus of clinical attention.
DiagnosticCode DisorderName
Principal Diagnosis:
Subtypes & Specifiers: Severity:
Diagnostic Criterion:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
DiagnosticCode DisorderName
Secondary Diagnosis:
Subtypes & Specifiers: Severity:
Diagnostic Criterion:
DiagnosticCode DisorderName
Tertiary Diagnosis:
Subtypes & Specifiers: Severity:
Diagnostic Criterion:
Clinician’s Name:
Signature: Date:
Supervisor’s Name:
Signature: Date:

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