Child and Adolescent Addendum Form (to complete with parent/guardian) *If any items are unknown, please mark with N/A.Email Address(Required) Any problems or concerns during pregnancy? (infections, trauma, exposure to alcohol, tobacco, or other drugs, etc.):(Required)Any complications during birth? (trauma, oxygen deprivation, birth defects, premature, postmature, birth weight, etc.):(Required)Developmental Milestones?(Required) Within Normal Limits Delayed Early Any problems with fine motor skills?(Required) No Yes Any problems with gross motor skills?(Required) No Yes Any problems with speech/language?(Required) No Yes Is the child adopted?(Required) No Yes If yes, what age? Does the child know? Describe early relationship of each significant caretaker with child (bonding & attachment)Mother Father Other Have client or siblings ever been removed from the home?(Required) No Yes If yes, type of placement, age, length of time? Has client ever run away from home or been gone more than 12 hours without permission?(Required) No Yes Are child's parents separated or divorced?(Required) No Yes If yes, date of split? Is either parent incarcerated?(Required) No Yes If child has been separated from siblings, where are siblings living? Have there ever been foster children/step-siblings/other children in the home for extended periods of time?(Required) No Yes Who does the child depend on for support with hard times?(Required) Relationship status (significant other?) and sexual orientation?(Required) Is peer group(Required) older younger same age mixed Do parents know peer group?(Required) No Yes Do parents approve of peer group?(Required) No Yes What school does child attend?(Required) Who is the guidance counselor?(Required) Main teacher or important teachers(Required) What is the highest grade level achieved and date?(Required) Has child repeated a grade?(Required) No Yes If yes, what grade? Has child's academic achievement level changed greatly?(Required) No Yes If yes, starting when? Any other school concerns & date concerns began?Has child ever been suspended?(Required) No Yes If yes, # of times Primary Reason Has child ever been suspended from bus?(Required) No Yes If yes, # of times Primary Reason Has child ever been expelled?(Required) No Yes If yes, # of times Primary Reason Is truancy an issue?(Required) No Yes If yes, # of unexcused absences this/last semester Has child ever been identified as requiring special education services?(Required) No Yes Behavioral Other Health Impairment Learning Disabled?(Required) No Reading Math Language Other Severity Regular Resource Self-contained Any sexual abuse?(Required) Unknown No Suspected Yes If yes, dates Age Relationship to abuser Any physical abuse?(Required) Unknown No Suspected Yes If yes, dates Age Relationship to abuser Any dating violence/rape?(Required) Unknown No Suspected Yes If yes, dates Age Relationship to abuser History of significant losses and age at time of event (frequent moves, loss of family or close friends, deaths, loss of pet, etc.)(Required)Has child ever tried drugs or alcohol?(Required) Unknown No Suspected Yes If yes, age? Substance(s)? Has child ever engaged in sexual activity?(Required) Unknown No Suspected Yes If yes, age? Is child engaged in extracurricular activities?(Required) What are child's strengths?(Required)Does your child watch TV?(Required) No Yes If yes, # of hours per day Does your child play video games?(Required) No Yes If yes, # of hours per day Does your child surf the internet?(Required) No Yes If yes, # of hours per day Supervision Status(Required) Supervised Unsupervised What are your child ls favorite things to play with?(Required)Does your child prefer to play(Required) Outside Inside Both How well does your child play with others?(Required) Very Well Sometimes Well Not Well Does your child prefer(Required) A lot of friends A few close friends How would you describe your child’s temperament?(Required) What is the primary method of discipline for your child?(Required) Your goals for your child in therapy(Required)
