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Completed By:
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Child's Name:
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E-Mail:
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Child's Date of Birth:
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(mm/dd/yyyy)
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Describe what you know about your child's birth family: age of parents,
number of siblings, family dynamics, abuse and/or neglect, drug and
alcohol abuse, crime, etc.
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List the number of disruptions (moves away from a family) your child has
experienced, reason for each, length of time and age in each placement,
and what degree of abuse, neglect or nurturing she/he received in each
placement.
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Describe any medical problems your child has experienced: e.g. inner
ear problems, colic, hospitalizations, premature birth, lack of prenatal
care, etc.
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Describe your child's first three years of life:
- Quality of prenatal care, birth and postnatal care?
- Did mother suffer postpartum depression?
- How did your child respond to holding, eye contact, and nurturance?
- What kind of emotional support was available for the mother during
the child's early years?
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Describe the progression of your child's disruptive behavior. How have you
reacted?
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Describe your child's positive attributes.
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Describe previous therapy your child and family has had, duration, and
results.
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Describe your hopes for bringing your child and family to Evergreen
Psychotherapy Center.
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Include a brief narrative describing a typical day in the life of your
child.
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