Child Psych Eval Packet

Child Psych Eval

Welcome! Thank you for choosing Northeast Rehab Therapy Services for your child.

It is our goal to work with you, the parents, or caregivers, to help your child reach his or her treatment goals. Beginning therapy for your child can be confusing and anxiety provoking. Our mission is to provide a comfortable safe space for your child to learn coping skills, increase mental wellness, and improve behavior. We believe that as a parent, you are a vital part of your child’s healthcare team. We are here to help you understand your child’s behavior by working and problem solving together.

Parents often play an active role in the therapy sessions. It has been my experience that parental involvement and follow-through greatly enhance the child’s progress and allows for continuity of care between sessions. I, therefore request that a parent or caregiver be present during each session, however therapy may include individual or family therapy depending on the treatment. Please arrange childcare for siblings during all therapy visits.

To assist in this process, please complete the questionnaire below prior to your child’s first appointment. You do not need to print. Once you complete and click submit, our office will securely receive your responses.

Also, before the appointment, consider writing down questions, topics, or issues you would like to focus on in your child’s sessions.

To ensure we are providing quality care, we need information from you and need to provide you with information about our practice policies. Below are links to our practice policies. Please click on each one to review prior to your visit. When you arrive for your appointment, you will be asked to electronically sign that you have reviewed and understand them.

Forms to be completed:

Medication intake form

Policies to view only

To provide you with secure electronic access to our physicians and staff, Northeast Rehab utilizes a Patient Portal. You need an access code to register. Once you receive your access code, you can click here to register. Through our patient portal, you can request appointments, update your medical history, medications, and allergies, and send a note to your provider. We encourage you to sign up for the Patient Portal before your first visit.

Patient First Name(Required)

Patient Last Name(Required)

Hidden

Date of Birth(Required)

Age(Required)

Primary Care Provider(Required)

What are your concerns that bring your child to therapy?(Required)

Pregnancy

Was the child born full term?(Required)

Any complications during pregnancy, labor, or delivery?(Required)

Please explain(Required)

How many weeks of Gestation?(Required)

Child's birth weight(Required)

Age of mother at delivery(Required)

Did mother receive prenatal care?(Required)

Did mother use alcohol, tobacco, recreational drugs during pregnancy?(Required)

What substances(Required)

How much/often(Required)

During which trimesters(Required)

Did the child exhibit motor delays?(Required)

Please explain(Required)

Did the child exhibit language delays?(Required)

Please explain(Required)

Did the child receive any developmental services?(Required)

If yes, what age and what services(Required)

How many siblings does the child have?(Required)

Please list ages(Required)

With whom does the child live?(Required)

Are the parents divorced?(Required)

What is the custody agreement?(Required)

Medical History

Current medical problems(Required)

Please explain(Required)

Any serious accidents, illnesses, or surgeries(Required)

Ever experienced a head injury, seizure, or other neurological insult?(Required)

Medical Health History

Has the child ever received any type of medical health treatment?(Required)

When was the first time and what type of services did he/she receive?(Required)

Was the child given a diagnosis?(Required)

What was the diagnosis?(Required)

Has the child ever taken psychotropic medications?(Required)

Name of medication(s)(Required)

Has the child ever been admitted to a psychiatric hospital?(Required)

Are there problematic behaviors or concerns at home?(Required)

Please describe the concerns(Required)

Has the child ever been arrested or involved with the legal system?(Required)

Describe the charges, consequences, and age(Required)

Has anyone in the family ever been diagnosed or treated for a mental health condition?(Required)

Who in the family and what condition?(Required)

Maternal(Required)

Paternal(Required)

School

What grade is the child in?(Required)

What school does he/she attend?(Required)

Is he/she receiving special education services?(Required)

What grade did the special edication services start?(Required)

Has the child ever been retained or required to repeat a grade?(Required)

What was the reason and grade?(Required)

Are there behavior problems at school?(Required)

Please describe those problems?(Required)

Does the child have difficulty paying attention or focusing in school?(Required)

Please describe(Required)

Does the child have difficulty completing homework?(Required)

Please describe(Required)

Has the child ever been suspended from school?(Required)

Please describe(Required)

Additional Questions

Can child maintain grooming? (brushing teeth, combing hair)(Required)

Is the child able to shower and dress independently?(Required)

Please describe(Required)

Does the child have problems with verbally expressing his/her needs?(Required)

Please describe(Required)

Does the child have problems comprehending what others say?(Required)

Please describe(Required)

Do you suspect use of abuse of drugs or alcohol?(Required)

Please describe(Required)

Has the child ever talked about wanting to hurt himself/herself?(Required)

Have you ever seen the child intentionally inflict self-harm by cutting, skin picking, burning self?(Required)

Please describe(Required)

Does the child have difficulty socializing with others?(Required)

Does the child have problems making or keeping friends?(Required)

Please describe(Required)

Have you ever suspected that the child is seeing or hearing things?(Required)

Please describe(Required)

Do you suspect your child suffers from anxiety, depression or self-esteem problems?(Required)

Do you have concerns regarding

Sleep

Appetite

Irritability

Self-isolation

Crying

Energy

Panic

Please describe(Required)

Does the child show unusual fear or distress related to:

Loud sounds (sirens, fire alarm, vacuum)

Touch on skin or face

Textures of clothes/tags in clothes

Seeing certain objects

Noisy, crowded places (theme park/mall)

Does the child flap hands or rock when excited or upset?(Required)

Use facial grimaces or tics(Required)

Toe walking(Required)

Does the child have preoccupation with any particular subject or toy(Required)

Difficulty adapting to change in routine(Required)

Does the child have any problems with visions(Required)

Please describe any vision issues(Required)

Does the child have any problems with hearing(Required)

Please describe any hearing issues(Required)

Child Psych Eval Packet

Child Psych Eval

Pregnancy

Medical History

Medical Health History

School

Additional Questions

Hassle Free Appointments

* New Patients Only