1. sports
2. football

Client Information Form
Name:_____________________________________Date of Birth:________________Age:_________
Address
_____________________________________________________________________
Phone Numbers:_____________________________________________________________________
Home
Mother’s Cell
Father’s Cell
INSURANCE INFORMATION
Insurance Company: ____________________________Policy Holder: _________________________
ID Number: ___________________________________Group Number: ________________________
Customer Service Number: ___________________________________________________________
REFERRED BY
Name
Phone Number
FAMILY INFORMATION
FATHER ___________________________________
B iological (
)
Adoptive (
)
Step (
)
Foster (
)
_______
Age
_________________
Current Occupation: ___________________________________________________________________________
Address if different from child’s: ____________________________________________________________________
MOTHER
__________________________________________
B iological ( ) Adoptive ( ) Step ( ) Foster (
_______
) Age
Current Occupation: ____________________________________________________________________________
Address if different from child’s: ____________________________________________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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PARENTS’ MARITAL STATUS
Current: Date of...Marriage
Previous Marriage: Mother married to
Father married to
Separation
Date Separated
_________ Date Separated
Divorce
Date divorce
Date divorced
______
FAMILY MEMBERS LIVING IN THE HOME
Name:__________________________________Name:__________________________________
Age:___________________________________ Age:____________________________________
Gender:________________________________ Gender:________________________________
Relationship:____________________________ Relationship:____________________________
Name:__________________________________Name:__________________________________
Age:___________________________________ Age:___________________________________
Gender:________________________________ Gender:________________________________
Relationship:____________________________ Relationship:____________________________
Name:__________________________________Name:__________________________________
Age:___________________________________ Age:___________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Gender:________________________________ Gender:________________________________
Relationship:____________________________ Relationship:____________________________
OTHER TREATING CLINICIANS
THERAPIST
Name
Phone Number
Address
PRIMARY CARE
Name
Phone Number
Address
OTHER
Name
Phone Number
LIST ALL CURRENT MEDICATIONS, VITAMINS, ADDITIVES & HERBALSUPPLEMENTS
NAME
DOSE
REASON OR PURPOSE
RESULT/EFFECT
REASON FOR BEING HERE AT THIS TIME
CURRENT PROBLEMS: What brings you here? Please briefly describe your child’s current problems
starting with the most serious.
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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ONSET: How long ago did the problems begin? How old was your child? Was there a precipitant?
Were there any major stresses happening in the family at the time the problems began?
TREATMENT: What kinds of interventions have been tried? Have you tried medications, seen other
therapists, used any “non-traditional” treatments?
FAMILY RELATIONSHIPS: Describe what effects the problems have had on family relationships and
family functioning. How does your child get along with each parent and with each brother and/or
sister?
SCHOOL: Describe your child’s function at school. Are there any problems? What are his/her schoolrelated likes and dislikes?
PEER RELATIONSHIPS: Describe how your child gets along with other children. Who are his/her best
friends? Have his/her problems affected these relationships?
PAST PSYCHOLOGICAL OR PSYCHIATRIC PROBLEMS
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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HAS YOUR CHILD EVER BEEN TREATED FOR ANY OTHER PSYCHOLOGICAL OR PSYCHIATRIC PROBLEMS
AT ANY OTHER TIME? Please describe other mental health problems and what interventions have
been made. What have been the results of these interventions?
CHILD’S DEVELOPMENTAL HISTORY
Start of Prenatal Care:______________________________________________________________
Did child’s biological mother have any of the following difficulties or complications during
her pregnancy with this child?
Yes
Spotting or light bleeding
Heavy bleeding requiring bed rest or special treatment
Excessive nausea or vomiting lasting more than 3 months
Weight gain over 30 pounds
Weight gain under 20 pounds
High blood pressure and/or excessive fluid build up
Convulsions during pregnancy
Toxemia
Pre-eclampsia
Gestational diabetes
Threatened miscarriage or early contractions
Accidents requiring medical care
Infection (like a kidney infection) requiring medical care
Illnesses requiring medical care
Anemia
Diabetes
Heart disease
Kidney disease
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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No
Not Sure
Measles/German measles
Flu or other virus
Exposure to X-rays just prior to or during pregnancy
Was this pregnancy considered “high risk”?
Maternal age over 40 years
Maternal age under 20 years
Was the pregnancy shorter than 38 weeks
Was the pregnancy longer than 42 weeks
During this pregnancy did mother do any of the following: Please check all that apply
Yes Trimester Frequency/Quantity
No
Not Sure
Smoking tobacco
Drinking alcohol
Any drug use (i.e.
marijuana, cocaine, ecstacy
Other:
Did biological mother take any medications during her pregnancy with this child? If yes, please list.
_____________________________________________________________________________________
_____________________________________________________________________________________
Labor and Delivery:
Length of Pregnancy:____________________________________________________________________
Went into early labor (reason):____________________________________________________________
Had Labor Induced: _____________________________________________________________________
Vaginal or C-Section Birth:________________________________________________________________
Baby’s Weight:____________________________
Baby’s Length:___________________________
APGAR Scores at delivery:___________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Length of stay in hospital after birth:_______________________________________________________
Complications during delivery:
Yes
No
Not Sure
Did the water break more than 24 hours before delivery
Prolonged labor (longer than 4 hours)
Was labor induced?
Was this child born breech (feet or head first )
Were forceps used?
Was suction used?
Was this a planned Caesarian section delivery
Was there an emergency Caesarian section
Was anesthesia used?
Were there seizures?
Infant required special care:
Yes
Was oxygen required?
Did the baby require an incubator?
Was this baby in the neonatal ICU?
Did the baby remain in the hospital after the birth mother went home?
Did the baby have jaundice?
Were there any difficulties with breathing?
Were there blood transfusions?
Were there seizures?
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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No
Not Sure
Infancy: Was there anything unusual, different or difficult about this child during the first
12 months of life?
Yes Provide Reason
No
Not Sure
Was surgery required?
Don’t include circumcision or tongue clipping
Had to switch formula 3 or more times
Had to use non-milk products
Cried, couldn’t be consoled
Too quiet or too good
Stiffened up when held
Pushed Parent away
Floppy or limp when held
Didn’t cuddle with you
Colicky
Hard to care for
Other:
Describe your child’s personality as a baby (easy or hard to sooth, responsive to you as caregiver, social)
_____________________________________________________________________________________
_____________________________________________________________________________________
At what age did your child:
Crawl:_____________ Sit up:_____________ Roll Over:________
Walk holding on:__________
Walk Alone:________ Self Feed:__________ Eat with a Spoon:_____ Drink From a Cup:_________
First Sounds:_______
Started Babbling:_____ First Word:_________ Sentences:_______________
Eye Contact:_________ Smiling:___________
Tracking Objects:_____ Play Patty Cake:___________
Play with toys:_______ Play with others:______Dry Daytime:________ Dry Nighttime:____________
Bowel Control:_______ Dress self:__________ Ride a tricycle:_______ Ride a bicycle:_______
Please Indicate if your child had any of these problems as an infant or young child (describe):
Delayed development or growth:___________________________________________________
______________________________________________________________________________
Separation Problems:_____________________________________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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_____________________________________________________________________________
Vision problems:_________________________________________________________________
Head Banging:___________________________________________________________________
Body Rocking:___________________________________________________________________
Hand Flapping:__________________________________________________________________
Toe Walking:____________________________________________________________________
Repetitive or unusual movements:__________________________________________________
______________________________________________________________________________
Make strange sounds or use strange language:________________________________________
Have any kind of speech impediment:_______________________________________________
Have discontinuous language development:___________________________________________
Have language development that stopped or regresses:_________________________________
Often repeat words or phrases just learned instead of responding to question asked:__________
______________________________________________________________________________
Use incorrect pronouns to refer to self:_______________________________________________
Use incorrect pronouns when referring to others:______________________________________
Seldom or never begins a conversation:______________________________________________
Required speech therapy:__________________________________________________________
Required occupational therapy:_____________________________________________________
Only talks to self not others:_______________________________________________________
Restlessness or over activity:_______________________________________________________
Attention Problems:______________________________________________________________
Aggression (hitting, biting, kicking):__________________________________________________
Defiance or resistance to authority:__________________________________________________
History of Trauma including sexual or physical abuse:____________________________________
_______________________________________________________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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MEDICAL HISTORY:
Are immunizations up to date? ____________________________________________________________
Has your child traveled to a foreign country in the last 10 years? Please list where and when.
_____________________________________________________________________________________
_____________________________________________________________________________________
Has your child ever been hospitalized? When and why?
Does your child currently have or ever had any serious medical illnesses? Please describe all illnesses
and their treatments.
Has your child ever had any serious injuries? Please include all head injuries. Describe all injuries
and their treatments. Did any require hospitalization?
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Has your child ever had surgery? Please describe the surgery. Include the date and outcome.
Does your child have any allergies? Please include all medication allergies or food allergies. Has your
child ever had any life threatening allergic reactions?
Does your child have asthma? Has it ever required visits to the emergency room or hospitalization?
Please describe the seriousness of the asthma and its past and current treatments.
Does your child currently take, or has he/she ever taken, any medication for medical, psychiatric or
behavior problems? List all medications including over the counter medication used for these
problems. Include both past and present medication use.
Medication
Dose
Reason or Purpose
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Result
Has your child ever tried, or does your child currently use, any chemical substances? Please list
alcohol, tobacco and illegal substances.
Substance
When Used
Frequency of Usage
When Stopped
Has your child ever been in trouble at home, at school or with the law because of substance use?
Please explain.
HEARING
Yes
Describe
Did your child have recurrent or chronic
ear infections?
Did he/she require surgery and/or tube
placement?
Has your child ever had a hearing
problem?
Has anyone ever questioned your child’s
ability to hear?
Last Hearing Screening
Does your child wear a hearing aid?
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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No
Not Sure
VISION
Yes
Reason
No
Not Sure
Reason/Description
No
Not Sure
Has your child ever had eye or vision problems?
Has your child been treated for strabismus or
“lazy eye”?
Has your child ever had any type of eye or
vision therapy?
Does your child wear prescription glasses or
contacts
Date of Last Eye Exam
NEUROLOGOCAL PROBLEMS
Yes
Head trauma or been hit in the head
Severe Headaches
Seizures
Seizures only with high fevers
Encephalitis
Meningitis
Loss of consciousness or black outs
Fainting
Momentary lapses of consciousness
Trance like episodes
Chronic dizziness
Double vision
Unexplained poor coordination
Trouble walking
Memory Problems
Has your child been exposed to toxic or dangerous chemical or materials?
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Yes
Reason/Description
Insulation
Asbestos Fumes
Metals Lead
Mercury
Plastics Solvents
Dyes
Chemicals
Does your child now, or has your child had a past history of or any problems with:
Now
Past
Never Explain
Head
Eyes
Ears
Nose
Throat
Respiratory system
Shortness of breath
Chest (i.e. pain)
Heart or blood vessels
Digestive tract
Liver (hepatitis, etc)
Genito-Urinary tract
Bones
Muscles
Hormone system
Brain or nerves
Sleep
Appetite
Females:
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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No
Not Sure
Age at first menstrual period
Is menstruation regular?
Are there any difficulties related to menstrual periods? Please explain
Is your child sexually active?
SOCIAL HISTORY
YES
NO
NOT
Describe relationships with parents or caregiver:
__________________________________________________________________________________
__________________________________________________________________________________
Describe relationships with siblings:
__________________________________________________________________________________
__________________________________________________________________________________
Describe your child’s current friendships:
__________________________________________________________________________________
__________________________________________________________________________________
Difficulty making or keeping friends:
__________________________________________________________________________________
__________________________________________________________________________________
Does your child prefer to play alone or with others?
__________________________________________________________________________________
What are your child’s strengths?
__________________________________________________________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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__________________________________________________________________________________
What are your child’s challenges/weaknesses?
__________________________________________________________________________________
__________________________________________________________________________________
Does your child ever feel guilt or remorse for wrong doings? If “yes” how does he/she show it?
_____________________________________________________________________________________
What does he/she like best about him/herself?
__________________________________________________________________________________
_____________________________________________________________________________________
Does your child make negative statements about him/herself? What are they?
__________________________________________________________________________________
__________________________________________________________________________________
Does your child get picked on or teased? What about or why? How does he/she handle it?
__________________________________________________________________________________
_____________________________________________________________________________________
How does your child handle peer pressure?
__________________________________________________________________________________
_____________________________________________________________________________________________________
Social withdrawal/problems:__________________________________________________________
Does he/she have a current boyfriend/girlfriend? ___________________________________________
Hobbies, Activities or sports involvement:
_________________________________________________________________________________
__________________________________________________________________________________
History of legal or police involvement:
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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__________________________________________________________________________________
__________________________________________________________________________________
Academic and Cognitive History:
Child began school at age:_________________Current Grade:_______________________________
Current School:_____________________________________________________________________
Address:___________________________________________________________________________
Phone:________________________________ Teacher:________________________________
Current Grades:_____________________________________________________________________
Has your child repeated a grade:_______________________________________________________
Is your child receiving special education services (if yes, explain services):
__________________________________________________________________________________
__________________________________________________________________________________
Has your child been suspended or expelled (if yes when & why):
__________________________________________________________________________________
__________________________________________________________________________________
Previous Schools (include reason for leaving):
Name
Grades Attended
Dates
Reason for Leaving
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
1.
Describe your child’s attitude toward school.
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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2.
Describe your child’s behavior in school.
3.
Has your child ever refused to go to school? If “yes”, please explain.
4.
Which are his/her best subjects?
Most difficult subjects?
5.
Have your child’s grades changed over time? If “yes”, please explain.
6.
Has your child had intellectual testing done? Please describe the results.
Cognitive Symptoms:
Poor short term memory:_________________________________________________________
Poor long term memory:_________________________________________________________
Reasoning:
Reasoning problems:_____________________________________________________________
Takes things too literally:_________________________________________________________
Difficulty understanding consequences of actions:______________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Difficulty with change:____________________________________________________________
Difficulty with transitions:_________________________________________________________
Language:
Problems understanding what others say:____________________________________________
Says “what” a lot:________________________________________________________________
Needs frequent repetition to understand:____________________________________________
Does not listen:__________________________________________________________________
Can’t follow a 3 step command:_____________________________________________________
Trouble expressing self verbally:____________________________________________________
Talks too much/too little:__________________________________________________________
Stutters:_______________________________________________________________________
Visuospatial:
Gets lost frequently:______________________________________________________________
Has trouble with directions:________________________________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Poor drawing ability:_____________________________________________________________
Poor penmanship:_______________________________________________________________
Child’s presenting problems: (Please indicated severity, age of onset or age of remission)
Sensitivity to noise:_____________________________________________________________________
Sensitivity to light:______________________________________________________________________
Sensitivity to clothing:___________________________________________________________________
Sensitivity with taste or smell:____________________________________________________________
Hates to be in crowds:________________________________________________________________
Ringing in the ears:_____________________________________________________________________
Nausea/Vomiting:______________________________________________________________________
Blurred vision:_________________________________________________________________________
Sleep problems:________________________________________________________________________
Eating problems:_______________________________________________________________________
Depression:___________________________________________________________________________
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Mood swings:__________________________________________________________________________
Irritability:____________________________________________________________________________
Anger:________________________________________________________________________________
Aggression:___________________________________________________________________________
Low frustration tolerance:________________________________________________________________
Can’t handle stress:_____________________________________________________________________
Anxiety:______________________________________________________________________________
Panic Attacks:__________________________________________________________________________
Paranoia:_____________________________________________________________________________
Hallucinations:_________________________________________________________________________
FAMILY HISTORY
Have any of your child’s relatives ever had any of the following:
Condition
Yes
No
Migraine or other chronic headaches
Seizures/Epilepsy
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Relationship to
Child
Stroke
High or Low Blood Pressure
Heart Disease
Heart Attack
Heart Murmur
Tuberculosis
Emphysema
Lung Disease
Asthma
Hay Fever
Stomach Ulcers
Gastric Reflux Disease
Gallstones
Diabetes
High Cholesterol
Liver Disease
Hepatitis
Kidney or Renal Disease
Nephritis
Thyroid Disease
Arthritis
Obesity
Infectious Disease
HIV/AIDS
Cancer
Anemia
Allergies
Hemophilia or Bleeding Tendencies
Sudden Unexplained Death
Alzheimer’s Disease
Dementia
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Genetic Disorder
Does any family member have any other medical illness or disorder, including hereditary disorders?
Have any of your child’s relatives ever been diagnosed with the following:
Condition
Yes
No
Depression
Manic Depressive (Bipolar) Disorder
Anxiety Disorder
Panic Disorder
Separation Anxiety
Agoraphobia
Obsessive Compulsive Disorder
Post-Traumatic Stress Disorder
Anorexia
Bulimia
Schizophrenia
Psychotic Disorder
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Relationship to child
ADHD
Oppositional Defiant
Disorder
Conduct Disorder
Antisocial Personality Disorder
Tourette’s Disorder
Tic Disorder
Autism
Asperger’s Disorder
Alcoholism
Substance Abuse
Has any family member ever taken any psychiatric medication?
Name
Medication
Purpose
Afg Guidance Center
444 Green Bay Road*Kenilworth, Illinois* 60043
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Relationship