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

Today's Date*

Date of Assessment*

Clinical ID #

Client Name*

First

Date of Birth*

Current Age*

Sex*

Male
Female
Prefer Not To Answer

Name of Person Completing Form*

First Last

Phone

Email

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Child/Adolescent's legal guardian:

First Last

Child/Adolescent's legal guardian:

First Last

Legal Guardian Email Address:

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Are there any custody or visitation agreements? If yes, please explain:

Referral Source

Community Providers

County

Family/Friend

Law Enforcement

Medical Facility

School/College

Self

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?

Other professionals (please explain):

If yes, please describe what services were provided or offered:

Please check the symptoms the client is having now

What areas have been impaired by the symptoms listed above:

Other? Please explain:

Chemical Use History

Has the client ever used tobacco? If yes, please describe the use:

Does the client drink alcohol or use drugs? What was the age of first use?

What is typical use and how much?

Has anyone been concerned by the client's chemical use?

Have there been any negative consequences or treatment involvement?

Has gambling ever been a concern and/or caused problems?

Please describe the family history of addictions or chemical dependency:

Medical History

Who is the healthcare provider?

When was the last physical exam?

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

List any medications the client is taking (Please include dosages and reason for use if known):

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

Does the client have any allergies? If yes, please list:

Has the client ever been hit in the head, or suffered head or brain trauma or injury? If yes, please explain:

Mental Health History

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

List the client's strengths and vulnerabilities:

Triggers and warning signs for relapse:

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

Date of service:	Where were you seen/treated:	Focus of treatment:

List current and previous medications that have been prescribed for mental health or psychiatric reasons (Please include dosages and reason for use if known)

Social/Relationship History

Has the client begun to date? If applicable, how old was the client?

Have these relationships been healthy, or has there been any maltreatment and/ or abuse?

Is the client sexually active?

Yes
No

Does the client have children? If yes, please provide name and age(s).

Describe the client's interests: (Include time with friends, hobbies, sports, etc)

Are there spiritual or cultural considerations you would like us to be aware of?

What are the client's coping skills?

Education/Work History

What school does the client attend?

Current Grade:

Describe the client's school 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?

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

Does the client have an Individualized Education Plan (IEP)? If yes, please describe the special needs and services provided. Please bring a copy.

Is there a family history of family academic problems or concerns? If yes, please describe.

Has the client had any kind of employment? If so, when and where:

Legal History

Does the client have any past or current legal problems?

If yes, for what? Please provide name of Probation Officer or Supervising Agent.

Have the client been ordered by court/ probation/ parole for assessment, to attend therapy or treatment?

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)?

Has the client been abused, neglected, or maltreated by anyone? If yes, please explain what happened:

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

Name, Relationship, Age, Occupation, Alive? (Yes/No)

If the parents were divorced, how old was the client at the time?

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?

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

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

Has the client known anyone that committed suicide?

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? Or as the client, what makes you a special and unique person?

Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

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

Yes
No

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

Yes
No

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

Yes
No

Did you often feel that no one in your family loved you or thought you were important or special? Or that you family didn't look out for each other, feel close to each other, or support each other?

Yes
No

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

Yes
No

Were your parents ever separated or divorced?

Yes
No

Was your 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 you 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

Now add up all your "Yes" answers. This is your ACE Score.

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