Note to individual completing this form: if the information in any item is "unknown" or "unavailable at this time," please indicate such and do not just leave items blank

Last Name*

First Name*

Middle Initial

Name Called By

Date of Birth*

Sex:
Male Female

What is child's current height?

What is child's current weight?

Current Address

City

Zip (+4)

Primary Language
English Spanish Other

Child's Social Security Number*

FOSTER AND/OR RELATIVE HOME INFORMATION (if applicable)

Foster Placement Relative Placement

Foster/Relative Name(s)*

Foster/Relative Home Address

City

Zip (+4)

Foster/Relative Home Phone

May we leave a message?
Yes No

Foster/Relative Cell Phone

May we leave a message?
Yes No

PROTECTIVE SERVICES WORKER INFORMATION

Worker Address

City

Zip (+4)

Worker Phone

Worker Fax

Last Name

First Name

Middle Initial

Home Address

City

Zip (+4)

Home Phone

Cell Phone

Date of Birth

Last Grade Completed

Mother's SSN (if known)

Last Name

First Name

Middle Initial

Home Address

City

Zip (+4)

Home Phone

Cell Phone

Date of Birth

Last Grade Completed

Father's SSN (if known)

SCHOOL RELATED INFORMATION

Does the child receive any special education services (e.g. special class placement, tutoring,speech therapy)?
Yes No

If yes, please specify which service(s)?

Has the child ever repeated a grade?
Yes No

If yes, which grade(s)?

Does/did the child attend a preschool program?
Yes No

If yes, please provide the following information:

Special Educational program provided by local public school because of qualifying condition (e.g. children with severe emotional and/or behavioral problems)?
Yes No

If yes, age(s) of child when attended:

Age of child during year(s) attended:

CHILD'S MEDICAL HISTORY

(If available, a physician's report from an exam performed by a protective services doctor may be substituted for this section. If applicable, attach report and initial here.)

Name of family physician/pediatrician, or medical clinic where child receives medical care

Address of physician/pediatrician, if known

Date of child's last medical examination (for any reason):

Are immunizations complete and up to date?
Yes No

Does the child have any food allergies? (list below)
Yes No

Does the child have other allergies? (list below)
Yes No

If yes, please list and describe reaction:

Other

Please describe any serious illnesses, injuries, operations and/or hospitalizations the child has experienced since birth (Do not include hospitalizations for psychiatric/emotional/behavioral reasons):

Illness, Operation, or Injury

Age of Child at the Time

If hospitalized, name of hospital and city

Illness, Operation, or Injury

Age of Child at the Time

If hospitalized, name of hospital and city

Illness, Operation, or Injury

Age of Child at the Time

If hospitalized, name of hospital and city

Has the child ever been hospitalized for psychiatric/emotional/behavioral reasons?
Yes No

If yes, when and name of hospital

Is the child currently taking any medication of any kind, prescribed or not?
Yes No

If yes, please provide the following information:

Medication Name

Reason for medication

How often each day?

For how long has she/he been taking it?

Medication Name

Reason for medication

How often each day?

For how long has she/he been taking it?

Medication Name

Reason for medication

How often each day?

For how long has she/he been taking it?

Does the child eat a nutritionally adequate diet?
Yes No

If no, what concerns do you have about the child's diet?

Does the child take multiple vitamins?
Yes No

Is the child on a special diet?
Yes No

If yes, what diet and are you comfortable monitoring it?

Does the child eat non-food items (e.g. dirt, chalk, rocks, paint, etc.)?
Yes No

If yes, please explain

Has the child experienced any unplanned or unusual weight loss or weight gain?
Yes No

The following might be considered "unusual" weight loss:
Young children: 2 pounds in 3 months or 5 pounds in 6 months
Teens: 5 pounds in 1 month or 10 pounds in 6 months

If yes, has the child experienced a recent illness or taken medications?
Yes No

If yes, what illness or medications

PREGNANCY AND BIRTH CIRCUMSTANCES

Please list any unusual circumstances known about child's birth or mother's pregnancy

DEVELOPMENTAL HISTORY

What was the child's weight at birth?

Unsure

Please list any known delays or deficits in the child's development (i.e. ambulation, language, toilet training, sleep patterns):

FAMILY MEDICAL HISTORY

Please list any known history of significant mental health or physical health problems in the child's biological family (who and what problem):

Do you have concerns about drug and/or alcohol abuse by anyone in the child's family, whether living in the child's household or not(not including the child - this will be responded to later)?
Yes No

If yes, by whom? Please explain

Is the child for whom you are seeking help on probation or parole or otherwise under the supervision of the Juvenile Court or Department of Youth Services?
Yes No

If yes, please explain

Apart from currently being in protective custody, is the child also the subject of a custody dispute between parents and/or other interested parties?
Yes No

If yes, please explain

Does there exist any Court Order that specifically prohibits either the mother or the father of the child from accessing information in medical records?
Yes No

If yes, please explain (and attach copy of Court Order, if available):

PREVIOUS ATTEMPTS TO GET HELP FOR THESE PROBLEMS

Is there a known history of prior attempts to get help for these or similar problems?
Yes No

If yes, please list the agencies and/or individuals you have received help from and the time period they were of service to you:

Please list any other major stressful events from the child's lifetime:

INFORMATION ABOUT THE CHILD

Please tell us the problem(s) with which you would like help and any preferences on how services might be provided:

Please describe the child's strengths and capabilities:

Does the child currently experience:

feelings of depression or unhappiness

Never Occasionally Frequently

loss of temper or feelings of anger

Never Occasionally Frequently

an unexplained physical symptom not due to an illness or medical condition

Never Occasionally Frequently

ALCOHOL /DRUG USE:

has the child ever drank alcohol of any kind (beer, wine, hard liquor)

Never Occasionally Frequently

has the child ever used street drugs of any kind

Never Occasionally Frequently

has the child ever used any prescribed drug for something other than its intended purpose

Never Occasionally Frequently

If has used any of the above please give known details:

SCHOOL RELATED INFORMATION

Does the child have a good attitude about going to school?
Yes No

If no, please explain:

Does the child demonstrate behavioral concerns at school?
Yes No

If yes, please explain:

Does the child typically complete their schoolwork?
Yes No

If no, please explain:

Approximately how many days of school did the child miss last year for any reason?

Are there concerns about the child's choice of friends?
Yes No

Are there concerns about the child's activities with his/her friends?
Yes No

Client Questionnaire (Protective Services)

CHILD INFORMATION

FOSTER AND/OR RELATIVE HOME INFORMATION (if applicable)

PROTECTIVE SERVICES WORKER INFORMATION

MOTHER INFORMATION

FATHER INFORMATION

SCHOOL RELATED INFORMATION

CHILD'S MEDICAL HISTORY

NUTRITION

PREGNANCY AND BIRTH CIRCUMSTANCES

DEVELOPMENTAL HISTORY

FAMILY MEDICAL HISTORY

LEGAL ISSUES

PREVIOUS ATTEMPTS TO GET HELP FOR THESE PROBLEMS

STRESSFUL EVENTS

INFORMATION ABOUT THE CHILD

Does the child currently experience:

Does the child:

Has the child:

ALCOHOL /DRUG USE:

SCHOOL RELATED INFORMATION

SOCIAL