Background Information

First Name Last Name Age Gender Date of Evaluation Clinician Given First Name Clinician Given Last Name Clinician Given ID
Dean Ween 14 years and 2 months male 2021-03-01 Dean Ween 12345

Dean Ween, a 14 years and 2 months year-old-male was evaluated on 2021-03-01. Dean’s mother completed the evaluation.

Important Dates

Event Date
Birth date 2006-11-29
Date of report 2021-03-01

Endorsed Questions and Answers

Background Information

Demographics

Question # Question Response
5 Child’s sex or gender Male
6 Child’s home address 123 St. 
7 Highest grade child has completed 9
8 Child’s school Highland HS
9 Child’s main teacher/advisor (if applicable) Mr. Cotter
10 Name of the person completing this form Gabrielle
11 Relationship of the person completing this form to the child Mother
12 Age of the person completing this form 45
13 Education of the person completing the form High School Diploma
14 Occupation of the person completing this form Graphic Designer
15 Ethnicity of the person completing this form European American/Caucasian (White, Anglo, White/Non-Hispanic)
16 Home phone of the person completing this form 123-456-7890
17 Cell phone of the person completing this form Same
18 Email address of the person completing this form
19 Child’s primary caregivers (select all that apply) Mother, Father
21 Do you know the father’s name? Yes
22 Marital status of the child’s parents Married
23 Was the child adopted? Yes
26 Is the child currently involved in any legal matters? Yes
29 What is the child’s ethnicity? European American/Caucasian (White, Anglo, White/Non-Hispanic)
30 Child’s primary language English
31 Mother’s primary language English
32 What language does the child use to speak with the mother? English
33 Father’s primary language English
34 What language does the child use to speak with the father? English
35 Language primarily spoken in the home English
37 What language does the child primarily use to speak with friends? English
39 Does any member of the family have a medical coverage group or a medical insurance company? Yes
40 Do you have a health care provider? Yes
41 Date of the child’s last physical examination 3 months ago
42 If you were referred, who referred you here? School

Family Members in House

Family Member's Name

Family Member's Sex

Relationship to Child

Family Member's Age

Maria

Female

Sister

11


Significant Family Members Outside of House

Significant Family Member's Name

Significant Family Member's Sex

Relationship to Child

Significant Family Member's Age

Steve

Male

Grandpa

70

Barb

Female

Grandma

68


Presenting Problem

PRESENTING PROBLEM

Question # Question Response
1 Briefly describe the child’s current problem for which you’re seeking services here Academic decline and drug use
2 How long has this problem been of concern to you? 3 months
3 When did you first notice the problem? 6 months ago
4 What seems to help the problem? Talking to father
5 What seems to make the problem worse? Father away on business
6 Have you noticed changes in the child’s behavior since the problem began? Yes
7 Has the child lost any skills? Yes
8 Have the child’s problems affected his or her relationship with other children? Yes
9 Have the child’s problems affected his or her relationship with his or her siblings? Yes
10 What seems to be the greatest challenge for the child? Completing school work
11 What does the child do that you like? Helps at home
12 What does the child do that other people like? Helpful
13 What makes you most proud of the child? Kind and thoughtful
15 Do you have any other concerns about the child that you have not mentioned above? Yes
16 What prompted you to seek help at this time? Suspension at school

   

 

Copyright 2019:Stoelting

Email Stoelting for support