Child Psychological Assessment

7 Sections ~20 min All fields optional

Adult Child Therapy Plan

Basic Information

Child Name

Age

Date of Birth

Gender

Male Female Other

Parent/Caregiver Name

Relationship to Child

Contact

Referred By

School

Grade

Presenting Concerns

Describe the main concerns

Duration

Severity

Mild Moderate Severe

Reported By

Parent Teacher Self Other

Developmental History

Pregnancy

Delivery

Developmental Milestones

Speech Development

Toilet Training

Medical Issues

Medical & Family History

Current Medical Problems

Medication

Allergies

Family Psychiatric History

Family Medical History

Academic / Social Functioning

Academic Performance

Good Average Poor

Learning Difficulties

Yes No

Social Interaction

Good Fair Poor

School Behavior

Peer Relationships

Provisional Impression

Additional Notes

All fields are optional. Fill in what you can.

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