Counseling Center of Nashua
 
                                                            One Main Street * Nashua, NH 03064   (603) 883-0005                                    
                                                            148 Coolidge Avenue * Manchester, NH  03102 * (603) 627-3111
                                                            294 D.W. Highway * Merrimack, NH  03054 * (603) 883-0005
                                                            50 Nashua Road * Suite 305 * Londonderry, NH  03053 * (603) 432-3033
                                                           208 Robinson Road * Suite 204 * Hudson, NH  03051 * (603) 598-9958
                                                           45 Main Street * Peterborough, NH  03458 * (603) 924-3331
                                                           61 NH Route 27 * Unit 10 * Raymond, NH 03077 * (603)689-7602
                                                           
414 State Street * Unit 2 * Portsmouth, NH  03801 * (603) 334-2533
                                                           24 Front Street * Suite 304 * Exeter, NH 03833 * (603) 778-2005  
                                                           16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222
                                                           319 Whittier Highway * Suite 8 * Center Harbor, NH 03326 * (603) 546-6178 
                                                                                          Fax all locations: 603-883-0007
                                 
                                          

CHILD / ADOLESCENT HISTORY FORM

PRIVACY NOTE:  This form meets HIPAA guidelines for privacy and secure electronic transmission.  Please note the lock on the bottom right corner of your web browser ensures your privacy, and all information is encrypted during transmission once completed.  Only administrative staff trained in HIPAA privacy rules and confidentiality will handle the print out of this document for delivery to your medical record prior and your provider.  Completion of this form will substantially expedite the information gathering process for your first appointment, and allow your provider to focus more specifically on the issues that require attention by avoiding additional spent on general background and medical information. Your cooperation is appreciated.

~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~

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Family Information

Mother's Information
Father's Information
Does the child have any step-parents?
0/460 characters
If parents are divorced,
do parents have joint legal custody?
Others Living in Home (Siblings, sgtep-siblings, grandparents, etc.)
 NameAgeEducationRelationship to child
1.
2.
3.
4.
5.
Other Siblings Not Living in Home
 NameAgeEducationRelationship to Child
1.
2.
3.
4.
0/720 characters

Pregnancy and Birth History

Was the delivery
Was this a planned pregnancy?
0/900 characters
Did the mother receive regular prenatal care during the pregnancy?
0/900 characters
0/900 characters

Developmental History

Child's Handedness
When did this child
 Roll over?Crawl?Take first steps?
first
 Speak first words?Speak in sentences?Toilet train?
first
Was this child ever referred for or did this child ever
receive early intervention services, or has this child
at any time received any speech and language therapy,
occupational therapy, or physical therapy services?
0/700 characters
0/900 characters

Child's Medical and Psychiatric History

Are this child's immunizations up to date?
0/320 characters
Has this child  been exposed
to poisons or toxins (e.g., lead)?
0/460 characters
0/900 characters
Does this child suffer from
any chronic illnesses
(e.g., asthma, diabetes, epilepsy)?
0/640 characters
Does this child have any problems with
0/900 characters
Is this child currently taking any medications for psychiatric or medical conditions?
If past psychiatric medications have been tried, please list below in next question.
0/800 characters
Has this child had any previous psychological, psychoeducational, neuropsychological, or neurological evaluations?
0/800 characters
Has this child ever received therapy services before?
0/800 characters

Any Challenges/concerns re: sleeping?
0/350 characters



Any challenges/concern re: eating?
0/350 characters
Does your child eat a balanced diet?
0/350 characters
Deos your pediatrician have any
concerns about your child's growth?
0/350 characters

Family Psychiatric and Medical History

0/1350 characters
0/1260 characters

Educational History

Did the child attend:
Nursery/Preschool?

Kindergarten?


How does the child perform academically?
          (1 = Above Average, 2 = Average, 3 = Below Average, 4 = Failing)
 1234
Math
Reading
Spelling
Writing
Science
Social Studies

Does this child have an IEP or 504 plan?
0/800 characters
Is this child in the gifted program?
Does this child miss school frequently?
0/640 characters
Has this child ever been suspended or expelled from school?

Does this child exhibit behavioral, social, or attentional problems at school?

Social and Emotional History

0/900 characters
0/450 characters
0/630 characters
0/540 characters
0/450 characters
How old are most of this child's friends?
0/720 characters
0/720 characters
0/720 characters
0/720 characters
0/720 characters
0/450 characters

Does this child engage in

0/450 characters
0/720 characters
0/720 characters
0/900 characters

Please check the following concerns that your child/teen has demonstrated in the last 3-6 months.

~~ Please Note:  Only complete this form if you have spoken to our Intake Department and have already scheduled your first appointment. If you have not, please complete the Request Appointment Form for an Adult or Child/Teen ~~