DEPARTMENT OF PSYCHIATRY AND BEHAVIORAL SCIENCES

PSYCHOLOGIST'S FORM CHILDREN

Biodata:
Name: ______________________________ Father’s / Guardian’s Name: ______________________

Age: ________________________________ Date of Birth: __________________________________

Sex: ________________________________ Education: ____________________________________

No. of Sibling: ________________________ Birth Order: ___________________________________

Religion: ____________________________ Address: ______________________________________

Contact No.: _________________________ Date of Admission: _____________________________

Informant: __________________________ Psychologist: __________________________________

Any Other Information: ____________________________________________________________________

Reason & Source of Referral

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Presenting Complaints
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History of Present Illness
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Family History
Father:

Alive / Late _____________________ Age ______________________ Education ___________________

Occupation _____________________ Temperament ___________________________________________

Relationship with client ____________________________________________________________________

Relationship with other children _____________________________________________________________

If Late:

When ____________________________ Cause death ________________________________________

Client’s age at time of father’s death __________________________________________________________

Client’s response toward death ______________________________________________________________

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Mother:

Alive / Late _____________________ Age ______________________ Education ___________________

Occupation _____________________ Temperament ___________________________________________

Relationship with client ____________________________________________________________________

Relationship with other children _____________________________________________________________

If Late:

When ____________________________ Cause death ________________________________________

Client’s age at time of father’s death __________________________________________________________

Client’s response toward death ______________________________________________________________

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Parental Relationship _____________________________________________________________________

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Family Environment:

Family System ___________________________________________________________________________

General Home Atmosphere ________________________________________________________________

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Family Members Living Together ____________________________________________________________

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Authoritative Figure ______________________________________________________________________

Significant Stressors ______________________________________________________________________

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Family Income ___________________________________________________________________________

Religiosity 1 ______ 2 ______ 3 _______ 4 ______ 5 ______ 6 _______ 7 ______ 8 _____ 9 ______ 10 _____

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Sibling Information
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Personal History:

Prenatal History

Any Medication during pregnancy ___________________________________________________________

Emotional Trauma during Pregnancy _________________________________________________________

Any illness (Psychiatric / medical) during pregnancy and post-partum period _________________________

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Pre-natal history

Type of delivery __________________________________________________________________________

First cry ________________________________________________________________________________

Any other information ____________________________________________________________________

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Postnatal History

Weight of baby ________________________________ Color of baby ____________________________

Any physical illness at the time of birth ________________________________________________________

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Type of feeding __________________________________________________________________________

Any feeding difficulty ______________________________________________________________________

Vaccination History _______________________________________________________________________

Other information ________________________________________________________________________

Departmental Milestones

Normal Age of Achieving

Milestones Client’s age of Achievement
Milestones
Head Holding 3 Months

Sitting with Support 6 Months

Sitting without Support 7 Months

Crawling 8 to 10 Months

Standing with Support 9 Months

Standing without Support 9 to 11 Months

Walking with Support 12 Months

Walking without Support 14 to 15 Months

Monosyllable speech 9 Months

Complete Sentences 3 Years

Bowel Control 3 Years

Dressing with Help 2 Years

Dressing without Help 3 to 4 Years

Bathing with Help 2 to 3 Years

Bathing without Help 4 to 5 Years

Present Health

General Health ___________________________________________________________________________

Height _________________________ Weight ____________________ Body Built _____________________

Hearing _______________________ Eyesight _____________________ Appetite _____________________

Sleep ______________________________________ Coordination _________________________________

Any Neurotic Pattern

 Nail Biting  Thumb Sucking  Stammering  Bed Wetting  Body Rocking

 Masturbation  Whistling  Head Banging  Pulling Hairs  Skin Picking

Emotional Behavioral Pattern

 Hostility  Disruptive  Abusive

 Quite  Continuous Crying  Continuous Worry

Interests

Play Hobbies ________________________________________________________________

Leisure Activities _____________________________________________________________

Liking ______________________________________________________________________

Disliking ____________________________________________________________________

Childhood Experiences
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Child’s Temperament / Traits / Behaviors before the Problem Started
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Child’s Temperament / Traits / Behaviors at Present

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Educational History

Age when started schooling ____________________________________________________

Progress in school ____________________________________________________________

Relations with teacher’s _______________________________________________________

Relations with Peer’s _________________________________________________________

Shifting in schooling __________________________________________________________

Extra-Curricular activities ______________________________________________________

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Sexual History _______________________________________________________________

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Occupational History __________________________________________________________

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History of Psychiatric / Medical Illness in Family

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Previous Psychiatric / Medical History
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Assessment
Formal Assessment
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Informal Assessment

Behavior Observation _________________________________________________________

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Finding on Medical Status Examination ____________________________________________

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Subjective Rating

Problematic Area

Diagnosis
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Important Differential Diagnosis

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Case Formulation / Conceptualization

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Management Plan

Short Term Goals

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Long Term Goals

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 SESSION REPORTS
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