Primary Care Physician: (Name, Phone Number, and Address)
Emergency Contact Information: (Name, Phone Number, Relationship)
Relation to Insured:
Family Members: (Please list - Name, Relationship, and Age of family members)
Has the child received counseling and/or play therapy before? Yes No If so, please list where and dates of services:
1. Is your child adopted? Yes No Has the child been told he/she was adopted?
2. Was the pregnancy planned?
3. How was the mother's health during pregnancy?
4. Was there anything unusual about the birth? (premature, length of labor, complications etc.)
2. Sleeping difficulties:
3. Does the child have their own bed?
4. Does the child wet the bed?
5. How many hours a night does the child sleep?
1. Activity Level:
1. Does the child have speech difficulties (stuttering, delays, etc.)
2. When did the child begin sitting?
3. When did the child begin standing?
4. When did the child begin Walking
5. Was the toilet training easy to complete?
6. Does the child still have soiling or wetting problems?
7. Any vision or hearing problems with the child?
1. Any unusual medical problems?
2. Has the child been hospitalized frequently?
3. Is the child on any medications now?
4. Are immunizations up to date?
5. Please list any doctors and/or professionals contacted:
1. Does someone other than mother/father/guardian have more than occasional responsibility for the child?
2. Is the child in day care?
3. Who disciplines the child? What methods are used?
4. Do parent(s) agree on discipline method and share responsibilities?
6. How effective has this been?
1. Does your child have many friends?
3. Has the family moved frequently?
4. Has the child had any problems in school? (please describe)
Academic (learning problems, special classes):
1. Has the child had any legal or juvenile court problems?
2. Has the child ever had any problems with alcohol or drugs?