Client History form RDI

Please complete and return. If you would like to provide additional information, please use the back of the form. Please submit any educational, neurological, or psychological records that you feel would benefit the therapist in learning about your child.

Today's Date

General Information

Name of Person filling out this form:

Relationship to Patient:

Do you have legal custody of the patient to make medical decisions for the patient?

Patient Information:

Patient legal name:

Patient's name they go by:

First NameLast Name

Patient's pronouns:

Other

Gender identity of patient:

Patient date of birth:

Address:

Preferred phone #:

Alternate phone #:

Emergency contact name:

Emergency phone #:

Email address:

Seeking the following Services:

In your own words, please share your reasons for initiating treatment. (problems, concerns, worries)

Primary reason(s) for seeking services:

Please select:

Language(s) spoken at home:

Please indicate what language you prefer services to be provided in:

Please answer the following questions to the best of your ability:

1. Goals: Write goals for treatment. Please be as specific as possible.

2. Opinions A: Is there any difference of opinion among different family members over whether problems exist, or what needs to be done? If so, please give us each person’s viewpoint of the problems and solutions.

3. Opinions B: How about others who know your child (i.e., teachers)? Have they noted any problems or differences? What is their view about what needs to be done to address these issues? Is there any difference of opinion between you and the school? If so, please give us their viewpoints as well as yours.

4. Living Arrangements: With whom does the child live at this time?

5. List all smokers living in home:

6. Child Expectations: Does the child know why he or she is coming? If so, what does he/she know and expect?

7. Marriage: Please tell us about parents’ marital status. Is this the first marriage for both? If there were prior marriages, are there any children from them? Are parents divorced? Remarried? Separated? If divorced, tell us your opinion of the impact of the divorce on the child. Is there any significant information about the parents’ relationship or treatment toward the child which might be beneficial in counseling?

8. Legal Issues: Please share any relevant legal issues of the client and/or family.

Information About Parent 1:

Parent 1 is:

Parent 1's Name

Parent 1's occupation

Is Parent 1 currently working?

Full time/Part time?

Name of employer:

Work phone #:

Parent 1's education:

Is there anything notable, unusual or stressful about the child's relationship with Parent 1?

Please explain:

How is the child disciplined by Parent 1?

For what reasons is the child disciplined by the Parent 1?

Parent 2 is:

Parent 2's name

Parent 2's occupation

Is Parent 2 currently working?

Full time/Part time?

Name of employer:

Work phone #:

Parent 2's education

Is there anything notable, unusual or stressful about the child's relationship with Parent 2?

Please explain:

How is the child disciplined by the Parent 2?

For what reasons is the child disciplined by the Parent 2?

11. Adoption: If your child was adopted, at what age was the adoption? What information do you have about the history of the biological parents and the child’s history before the adoption?

12. Brothers and sisters: Tell us any important information about siblings that would help us. Please include quality of the relationship with client.

13. Caregivers: Please tell us about the adults involved with this child on a regular basis.

14. Family Health:

Have any of the following diseases occurred among the child’s blood relatives? (parents, siblings, aunts, uncles or grandparents) Check those which apply:

Comments about Family Health:

15. Stress: Please tell us about any recent stresses and crises that have occurred in the family in the last few years. For any stress you list, tell us how you think it may have affected your child. Include a parent who must work unusually long hours in the list of stresses. Also, include any anticipated future stresses.

16. Pregnancy: Please tell us about the pregnancy and delivery of this child. Were there any stresses or problems?

17. Early: Please tell us anything significant about this child’s first months of life. What, if anything did you notice was significant in the first year? What about his or her development was different from what you expected? Please include anything physical, psychological, or social.

18. First 18 months: Please share anything you feel is especially notable about the child’s early development during the first 18 months. What about his or her development was different from what you expected? Please include anything physical, psychological, social, intellectual, or academic.

19. 18 months to present: Please share anything you feel is especially notable about the child’s early development between 18 months and presently. What about his or her development was different from what you expected? Please include anything physical, psychological, social, intellectual, or academic.

20. Medical History: Please share anything notable about the child’s medical status, including neurological problems and allergies.

Does the client have a Primary Care Physician (PCP)?

If yes, provide name and contact information:

May we contact your PCP?

List any drug or food allergies (if any): Please include adverse sections:

List any current health concerns:

List any recent health or physical changes:

Current prescribed medications

Rows	Name of Medication	Dose	Dates	Purpose	Side Effects
Medication #1
Medication #2
Medication #3
Medication #4

Current over-the-counter meds:

Rows	Name of Medication	Dose	Dates	Purpose	Side Effects
Medication #1
Medication #2
Medication #3
Medication #4

Medical Health History:

Provider #1 Name and Contact

Date (or date range)

Purpose of seeing Provider #1:

Response:

Can we contact provider #1 (Y/N)?

Add another provider?

Provider #2 Name and Contact

Date (or date range)

Purpose of seeing Provider #2:

Response:

Can we contact provider #2 (Y/N)?

Add another provider?

Provider #3 Name and Contact

Date (or date range)

Purpose of seeing Provider #3:

Response:

Can we contact provider #3 (Y/N)?

Add another provider?

Provider #4 Name and Contact

Date (or date range)

Purpose of seeing Provider #4:

Response:

Can we contact provider #4 (Y/N)?

Add another provider?

Provider #5 Name and Contact

Purpose of seeing Provider #5:

Date (or date range)

Response:

Can we contact provider #5 (Y/N)?

Add another provider?

Provider #6 Name and Contact

Purpose of seeing Provider #6:

Date (or date range)

Response:

Can we contact provider #6 (Y/N)?

21. Behavioral/Emotional: Please check any of the following that are typical for your child:

22. Behavioral Health History: Please share any current/past treatment by another behavioral health clinician (e.g. psychiatrist, and social worker, psychologist and substance abuse counselor)

Provider #1 name and contact info:

Date seen (or date range)

Purpose of seeing Provider #1:

Response:

Can we contact Provider #1 (Y/N)?