The Counseling Center Of New England

One Main Street * Nashua, NH 03064 * (603) 883-0005

8 Auburn Street * Nashua, NH 03064 * (603) 883-0005

15 Trafalgar Sqare * Nashua, NH 03063 * (603) 883-0005

148 Coolidge Avenue * Manchester, NH 03102 * (603) 627-3111

294 D.W. Highway * Merrimack, NH 03054 * (603) 883-0005

77 Gilcreast Rd * Suite 3000 * Londonderry, NH 03053 * (603) 432-3033

45 Main Street * Peterborough, NH 03458 * (603) 924-3331
414 State Street * Unit 2 * Portsmouth, NH 03801 * (603) 334-2533

24 Front Street * Suite 100 * Exeter, NH 03833 * (603) 778-2005

16 Lincoln Street * Suite C * Brunswick, ME 04011 * (207) 406-4222

53 Baxter Blvd. * Portland, ME 04103 * (603) 883-0005

61 NH Route 27, Unit 10 * Raymond, NH 03077 * (603) 689-7602

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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Today's date * +

Name of person completing form *

Your email address *

Date of First Appointment

Name of the Provider patient will be seeing *

2nd Provider (if more than 1):

First Name *

Last Name *

Birth Date *

Sex *

Parent/guardian contact email address *

Pediatrician / PCP - FIRST & LAST Name Please

Emergency Contact - Name and Number *

Family Information

Mother's Information

First Name

Last Name

Birth Date

Age

Marital Status

Education

Occupation

Father's Information

First Name

Last Name

Birth Date

Age

Marital Status

Education

Occupation

Parents' marital status

Does the child have any step-parents?

Yes

No

If so, please provide names and dates of relationships

0/460 characters

If parents are divorced,
do parents have joint legal custody?

Yes

No

What is the current visitation schedule for this child?

Others Living in Home (Siblings, sgtep-siblings, grandparents, etc.)

	Name	Age	Education	Relationship to child
1.	Name	Age	Education	Relationship to child
2.	Name	Age	Education	Relationship to child
3.	Name	Age	Education	Relationship to child
4.	Name	Age	Education	Relationship to child
5.	Name	Age	Education	Relationship to child

Other Siblings Not Living in Home

	Name	Age	Education	Relationship to Child
1.	Name	Age	Education	Relationship to Child
2.	Name	Age	Education	Relationship to Child
3.	Name	Age	Education	Relationship to Child
4.	Name	Age	Education	Relationship to Child

Please describe any geographical and/or school moves this child has made

0/720 characters

Pregnancy and Birth History

Length of pregnancy

Duration of Labor

Birth Weight

Age of mother at delivery

Was the delivery

Vaginal

Routine Caesarean

Emergency Caesarean

Was this a planned pregnancy?

Yes

No

Did the mother experience any complications during her pregnancy (e.g., gestational diabetes, preeclampsia, serious illnesses
or injuries, extreme stress)?

0/900 characters

Did the mother receive regular prenatal care during the pregnancy?

Yes

No

Did the mother/baby experience any complications during the child's birth (e.g., emergency c-section, infection, excessive
bleeding, premature labor, etc)?

0/900 characters

Did the child experience any complications during delivery or in the hours following birth (e.g., premature birth, difficulty breathing,
seizures, fever, jaundice, maconium staining, significant heart rate deceleration, cord wrapped, etc.)? Please indicate your child's
two apgar scores, if known, at the time of birth.

0/900 characters

How old was this child at discharge from the hospital after birth?

Developmental History

Child's Handedness

Right

Left

Both

When did this child

	Roll over?	Crawl?	Take first steps?
first	Roll over?	Crawl?	Take first steps?

	Speak first words?	Speak in sentences?	Toilet train?
first	Speak first words?	Speak in sentences?	Toilet train?

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?

Yes

No

If yes, please provide dates and providers

0/700 characters

How would you describe this child's temperament in the first year of life?

0/900 characters

Child's Medical and Psychiatric History

Are this child's immunizations up to date?

Yes

No

If no, please describe

0/320 characters

Has this child been exposed
to poisons or toxins (e.g., lead)?

Yes

No

If yes, please list what they were exposed to and when

0/460 characters

Please describe any accidents, injuries, head injuries, loss of consciousness, concussions, major illness, surgeries, or
hospitalizations this child has experienced.

0/900 characters

Does this child suffer from
any chronic illnesses
(e.g., asthma, diabetes, epilepsy)?

Yes

No

If yes, please list illnesses

0/640 characters

Does this child have any problems with

If any items are checked, please explain briefly including any other unusual thoughts or behaviors that are concerning to you.

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.

Yes

No

If yes, please provide reason, dosage, effectiveness, side effects, and prescribing provider.

0/800 characters

Has this child had any previous psychological, psychoeducational, neuropsychological, or neurological evaluations?

Yes

No

If yes, please include dates of evaluations and names of providers. Please bring copies with
you to your first appointment so they can be left in your child's medical record.

0/800 characters

Has this child ever received therapy services before?

Yes

No

If yes, please provide dates and names of providers.

0/800 characters

Any Challenges/concerns re: sleeping?

Yes

No

If yes, please explain:

0/350 characters

If yes, when did this begin?

What time does your child go to bed?

Any challenges/concern re: eating?

Yes

No

If yes, please explain:

0/350 characters

Does your child eat a balanced diet?

Yes

No

Please explain either answer:

0/350 characters

Deos your pediatrician have any
concerns about your child's growth?

Yes

No

If yes, please explain:

0/350 characters

Family Psychiatric and Medical History

Below, please provide any information you have regarding any family history of psychiatric issues (i.e. depression, anxiety,
bipolar disorder, substance abuse, schizophrenia, dementia, OCD, attention deficit disorder, suicide, etc)

0/1350 characters

Below, please list the major physical health issues of biological family members and their relationship to you.

0/1260 characters

Educational History

Did the child attend:

Nursery/Preschool?

Yes

No

If so, where?

Kindergarten?

Yes

No

If so, where?

What school is the child currently attending?

What is the child's current grade?

Who is his/her teacher?

Has the child repeated any grades?

Has the child skipped any grades?

How does the child perform academically?
(1 = Above Average, 2 = Average, 3 = Below Average, 4 = Failing)

	1	2	3	4
Math	1	2	3	4
Reading	1	2	3	4
Spelling	1	2	3	4
Writing	1	2	3	4
Science	1	2	3	4
Social Studies	1	2	3	4

Does this child have an IEP or 504 plan?

Yes

No

If yes, please describe.

0/800 characters

Is this child in the gifted program?

Yes

No

Does this child miss school frequently?

Yes

No

If yes, please explain.

0/640 characters

Has this child ever been suspended or expelled from school?

Yes

No

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

Yes

No

Social and Emotional History

In your opinion, what mood is this child in most of the time?

0/900 characters

Does this child exhibit frequent mood changes?

0/450 characters

Does this child have significant fears, or does this child worry a great deal?

0/630 characters

Does this child demonstrate poor attention, hyperactivity, impulsive behavior, or temper tantrums?

0/540 characters

How many friends does this child have?

How much time does this child play with friends per day?

How well does this child make and keep friends?

0/450 characters

How old are most of this child's friends?

Same Age

Older

Younger

How does this child get along with peers?

0/720 characters

How does this child get along with his/her siblings?

0/720 characters

How does this child get along with adults (e.g., parents, teachers, coaches)?

0/720 characters

Does this child exhibit any problems with defiance of adult requests?

0/720 characters

What methods have you used to discipline this child? Have they been effective?

0/720 characters

Do all of this child's caregivers agree on how to discipline this child and which behaviors to discipline?

0/450 characters

Does this child engage in

Has this child ever been arrested or involved in a legal matter?

0/450 characters

What are this child's favorite activities?

0/720 characters

What are this child's best qualities?

0/720 characters

Please describe the reason you are seeking services and provide as much detail as you would like.

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 ~~

Vision	Hearing	Gross Motor
Fine Motor	Heachaches	Stomachaches/Vomitting
Allergies	Falling Asleep	Staying Asleep
Early Rising	Bedtime Fears	Restlessness
Bladder/Bowel Control	Tics	Nervous Habits
Repetative Movements	Increased Appetite	Decreased Appetite
Cutting Self	Hitting Self	Burning Self

Stealing	Lying
Fire Setting	Running Away
Truancy from School	Cruelty to People
Cruelty to Animals	Destruction of Property

Aggressive behavior	Alcohol abuse/overuse	Anger outbursts
Anxiety or excessive fear/worry	Attention/concentration problems	"Bad" friends
Bingeing	Decreased energy	Decreased sex drive
Depressed/down/unhappy mood	Dissociative states	Divorce adjustment
Euphoria	Fears/phobias	Flashbacks
Grief	Guilt (excessive)	Hallucinations
Having extra energy	Hopelessness/helplessness	Hyperactivity
Hypersexuality	Impulsivity	Insomnia
Irritability	Learning problems	Marijuana or other drug use
Memory problems	Mood fluctuating rapidly up and down	Obsessions/compulsions
On guard or edgy	Oppositional behavior	Panic attacks
Paranoid thoughts	Pressured/rapid speech	Purging behaviors
Restricting food intake	School avoidance	Social/peer problems
Sleep problems/little or too much	Somatic/physical complaints	Weight gain (significant)
Weight loss (significant)	Worthlessness