Child Evaluation Form (ages 0-5) • Zumbro Valley Health Center

Today's Date*

Date of Assessment*

Clinical ID #

Client Name*

First Last

Date of Birth*

Current Age*

Sex*

Male
Female

Name of Person Completing Form*

First Last

Phone*

Email

Enter Email Confirm Email

Legal Guardian(s)

First Name	Last Name	Email Address

Are there any custody or visitation agreements?

Yes
No

Please explain:

Referral Source

Community Providers

County

Family/Friend

Law Enforcement

Medical Facility

School/College

Assessment Overview

Presenting Problem(s)/Reason for Assessment*

Please provide examples of behaviors that you are concerned about.

When did the problems begin?*

What have you already done to help with the problems?*

Are there, or have there been, other professionals involved in the client's care?

Yes
No

Select all that apply:

Please list any other professionals:

Please describe what services were provided or offered:

Please select the symptom(s) the client is currently displaying:

(select all that apply)

What areas have been impaired by the symptoms listed above:

(select all that apply)

Please list any other areas that have been impaired:

Chemical Use History

Please describe any family history of addiction or chemical dependency:

Medical History

Who is the client's healthcare provider?

When was the client's last physical exam?

Describe any current medical problems or physical symptoms the client is having:

List any medications the client is taking:

Name of Medication	Dosage (if known)	Reason for use (if known)

Please list any important medical information (illnesses, injuries, surgeries, drug side effects, etc.):

Does the client have any allergies?

Yes
No

Please list all known allergies:

Has the client ever been hit in the head, or suffered head or brain trauma or injury?

Yes
No

Please explain:

Mental Health History

Has the client had thoughts or actions of suicide or self-harm? Or harming another person?

Yes
No

Please explain:

List the client's strengths and vulnerabilities:

List the client's triggers and warning signs for relapse:

Please list previous mental health services (include therapy, psychiatry, hospitalizations, commitments, county services, etc):

Date of service	Where the client was seen/treated	Focus of treatment

List current and previous medications that have been prescribed for mental health or psychiatric reasons:

Medication	Dosage (if known)	Reason for use (if known)

Social/Relationship History

Describe the client's interests:

(time with friends, hobbies, sports, etc.)

Please list any spiritual or cultural considerations you would like us to be aware of:

What are the client's coping skills?

Education/Work History

What school or daycare does the client attend?

Current grade (if applicable):

Describe the client's school and/or daycare experience:

(Please be specific and include how many schools the client has attended, academic progress, social involvement, extra-curricular involvement, getting along with teachers and peers, etc.)

Have there been any difficulties in school and/or daycare?

(Please include in/out of school suspensions, expulsions, truancy, or other academic issues)

Does the client have an Individualized Education Plan?

Yes
No

Please describe the special needs and services provided.

Please bring a copy of the plan to the client's appointment.

Is there a family history of family academic problems or concerns?

Yes
No

Please describe:

Family History

Where was the client born and where has he/she lived since?

What has growing up been like for the client?

Has the client been exposed to violence in the family or elsewhere (verbal, emotional, sexual, physical)?

Yes
No

Please explain:

Has the client been abused, neglected, or maltreated by anyone?

Yes
No

Please explain what happened:

Please complete the following information about significant caregivers the client has lived with: (parents, step, grand, or foster-parents, etc.)

Name	Relationship	Age	Occupation	Alive? (Yes/No)

Are the client's parents divorced?

Yes
No

How old was the client at the time of the divorce?

Please complete the following information about sibling, step-siblings, or half-siblings:

Name	Relationship	Age	Occupation	Alive? (Yes/No)

Who currently lives in the home with the client?

Name	Relationship

Please describe the current relationships with the parents / caregivers / siblings:

Have any family members been treated for or diagnosed with a mental illness?

Yes
No

Please explain:

Has the client known anyone that committed suicide?

Yes
No

Please explain:

Are you aware of any developmental problems or concerns from pregnancy / birth / childhood / adolescence? Was there the potential for maternal chemical use during pregnancy?

At about what age did the client complete the following?

(mark NA if not yet obtained)

Walk alone:

Complete toilet training:

Speak in sentences:

Sleep through the night:

Discontinue bed wetting:

Other:

Have there been any concerns about the client meeting these developmental milestones or any others?

Coordination of Care

Please list any other service providers that are assisting the client:

Please give any additional information that may be important or beneficial in treating the client:

What do you enjoy most about the client?

Adverse Childhood Experience (ACE) Questionnaire

Please answer yes or no to all of the following questions for an accurate score.

Did a parent or other adult in the household often swear at the client, insult the client, put the client down, or humiliate the client? Or act in a way that made the client afraid that they might be physically hurt?

Yes
No

Did a parent or other adult in the household often push, grab, slap, or throw something at the client? Or ever hit the client so hard that the client had marks or was injured?

Yes
No

Did an adult or person at least 5 years older than the client ever touch or fondle the client, or have the client touch their body in a sexual way? Or try to or actually have oral, anal, or vaginal sex with the client?

Yes
No

Did the client often feel that no one in their family loved them or thought they were important or special? Or that the client's family didn't look out for each other, feel close to each other, or support each other?

Yes
No

Did the client often feel that they didn't have enough to eat, had to wear dirty clothes, and had no one to protect them? Or the client's parents were too drunk or high to take care of the client or take the client to the doctor if they needed it?

Yes
No

Were the client's parents ever separated or divorced?

Yes
No

Was the client's mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Or sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes
No

Did the client live with anyone who was a problem drinker or alcoholic or who used street drugs?

Yes
No

Was a household member depressed or mentally ill or did a household member attempt suicide?

Yes
No

Did a household member go to prison?

Yes
No

This is the client's ACE score:

Phone

This field is for validation purposes and should be left unchanged.

Aches/pains
Anxious/nervous
Ashamed
Blames others
Body image concerns
Can't enjoy myself
Choking feeling
Cry easily/often
Depressed/sad
Destroys property/fires
Difficulty breathing
Distressing memories
Disturbing thoughts
Dizziness
Eating/appetite concerns
Elevated mood
Excessive worry
Feel inferior
Feel unworthy
Feeling paranoid/suspicious
Forgetful
Frequent mood swings
Frustration
Guilt feelings
Headaches
Hear voices
Heart racing
Heavy feeling
Hoarding
Hopelessness
Hyperactivity
Impulsive
Irritable/angry
Lack of motivation
Lies/steals
Loneliness
Lose temper
Low energy/tired
Low self-esteem
Motor or verbal tics
Nightmares
Numbness/tingling
Physical aggression/cruelty to animals
Poor concentration
Poor memory
Racing thoughts
Repetitive actions
Restless/fidgety
See images or objects
Self harming behaviors/urges
Sexual issues/concerns
Shaking
Sleep problems
Social discomfort
Tense feelings
Thoughts of wanting to die
Thoughts of wanting to hurt others
Wound up