Clinical Interview Form – Child Today's Date MM slash DD slash YYYY Child's Name First Last Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone NumberParents' NamesParents' Contact Phone #Alternate Parents' Contact Phone #Child's Date of Birth MM slash DD slash YYYY AgeRaceLanguages SpokenCurrent SchoolGrade LevelIn special education? Yes No If yes, please describe.Educational StrengthsEducational WeaknessesPresenting Problem (Reason for seeking services)When did the problem start?FrequencySeverity Mild Moderate Severe Signs and Symptoms of Impairment(s) (e.g., social, educational, affective, cognitive, physical). Please explain.History of Presenting Problem (Events, precipitating factors, stressors, and/or incidents leading to need for services) Please explain.Was there a clear time when symptoms worsened?Describe any family mental health history.Family Mental Health HistoryCurrent Family and Significant RelationshipsStrengths / supportStressors / problemsRecent changesChanges desiredComment on family circumstancesChildhood/Adolescent HistoryDevelopmental HistoryWas your pregnancy with your child without complications? Yes No Was the delivery of your child without complications? Yes No How much did your child weigh at birth?Did your child have any complications after delivery? Yes No How would you describe your child’s temperament as an infant?At what age did your child sit-up?At what age did your child crawl?At what age did your child walk?At what age did your child potty train?Any problems/issues with any of these developmental milestones? Yes No Please explain.Has your child ever been abused? Yes No What form of abuse? Physical abuse Sexual abuse Emotional abuse Please explain.Social RelationshipsStrengthsWeaknessesLeisure/RecreationalHobbiesPhysical Health/Medical HistoryHas child ever had a head injury? Yes No When?Loss of consciousness? Yes No How long?Medical conditions (past and present)Name of your child's pediatrician. First Last Counseling/Prior Treatment HistoryHas the child received counseling services in the past? Yes No With whom and when?Benefits of previous treatmentSetbacks of previous treatmentCurrent MedicationsPlease check all that apply Eating difficulties Sleep impairment Impulse control problems Thought disorders Anger issues Relationship problems Phobias Suicidal ideation Anxiety Depressed mood Irritability Obsessive or compulsive behavior Substance abuse issues Please explain
