Child Biographical Form

An in-depth intake form for child therapy practices, gathering family, developmental, academic, and emotional background on the child.

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Page 1

Name

Nombre

Apellido

Client ID Number

Client Date of Birth

Client Age

Client Mobile Number

Client Email Address

School (Child Minor)

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Reason For Therapy/Assessment

Emotional or behavioral difficulties Academic difficulties Developmental concerns Family issues Other

Page 2

Home Language of Child

Spanish English Portuguese Other

Name, Age and Grade of All Siblings

If Divorced, with whom do the children reside with?

Nombre

Apellido

Current Difficulties

Birth Weight

Age in months

What nursery and/or other primary schools did your child attend (please indicate the years)?

How did your child adjust to school when he/she went for the first time?

Has this attitude ever changed for some or other reason?

Please provide some details

What are your child's current academic difficulties?

Does/did your child attend any other therapy?

Yes, attends other therapy

Does your child have any difficulties with

If yes, please elaborate?

In general, please describe your child's Strengths:

In general, please describe your child's Vulnerabilities:

In general, please describe your child's Coping skills:

Please select which personality characteristics most apply to your child. Please select at least 3.

Who would you consider your child's support system to be? Close friendships etc

How does your child respond to discipline at home?

How does your child respond to discipline from others?

How does your child spend his/her leisure time?

As a family, how do you spend your leisure time?

What jobs do both parents do?

Medication name and dosage

Please supply information regarding your child's sleeping patterns / appetite / energy levels / concentration and attention. Is there anything you are concerned about in these areas?

How would you describe your child in terms of his/her predominant emotions and feelings at present?

Does your child have any fears that you are aware of? If so, what are they?

Does your child show signs of being anxious? If so, what do you think causes the anxieties?

Please select any of the following currently applies to your child:

Please elaborate and explain

If yes, please elaborate?

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Child Biographical Form

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