Application Packet and Processing Information

Child History Report

Please provide a NARRATIVE description of your child. Include:

1. History of problem behavior

2. Medical problems

3. Adoption history and process, if applicable

-Please discuss how you made the decision to adopt

4. A summary which will help give us a clear understanding of your child's difficulties

Please contact us if you have any questions.

Physician's Statement

Prior to your child's participation in treatment in this office, I am requesting that he/she have a physical by your family physician or pediatrician. This physical should approximate one that is given for sports activities. A physician statement is required indicating that the child is free from any medical condition that would preclude his/her participation in physical exercises that may be rigorous. While this may seem somewhat confusing, we do require some individuals to do pushups, running in place, and kicking while lying on their backs. This is not done for extended periods of time. However, at times throughout the treatment we may expect such activities.

You may feel free to share this letter with your physician, and if there are any questions, please encourage your physician to contact me. The results of the physical and medical clearance statement must be received in this office prior to the scheduled assessment date.

For the Parents/Caregivers

Caregiver's/Parent's Autobiography Outline

It is always helpful for us to have as much information about family history, style, and overall functioning as possible before beginning the intensive treatment program. To get this information, we have found that autobiographical statements of the caregivers/parents have proven invaluable. Therefore, it would be helpful if each caregiver/parent would prepare a narrative statement that addresses the issues solicited by the following questions. PLEASE DO NOT GO THROUGH THIS LIST OF QUESTIONS AND ANSWER THEM. WRITE A SUMMARY OF YOUR LIFE EXPERIENCES IN NARRATIVE STYLE. Include in the summary discussion of the issues that the questions are addressing. If there are other areas that are important, also include them. Contact us if you have any questions.

MENTAL HEALTH OF PARENTS

-Did either of your parents often complain of physical problems that were not medically confirmed?

-Was either of your parents often depressed, noticeably unhappy or irritable?

-Did either of your parents have problems with alcohol?

-Did your parents often argue?

-Was there ever physical violence between your parents?

-Were there other significant difficulties of your parents particularly during your early childhood?

-Please describe the good and bad characteristics of your parents.

DIVORCE AND STEPPARENTS

-Did your parents divorce? If so, please answer the following:

-At what age were you when your parents separated?

-With whom did you live?

-Was there a stepparent in the home?

-How old were you when the stepparent entered your life?

-How did the stepparent handle control issues with you?

AFFECTION

-Please describe affectionate behavior of your parents or caretakers, or lack of it. Please give frequency and your reactions. Would you be more or less affectionate with your child? Why?

ROLE IN FAMILY

-What role did you have in your family of origin and how do you see that influencing your relationship to a child?

DISCIPLINE

-How did your parents discipline you?

-Do you agree with their behavior? Why?

-In what ways have you changed?

ABUSE

-Do you feel that either of your parents, or caretakers was ever abusive? If so, in what way?

-How have you dealt with your feelings about this issue?

NEGLECT

-Were there any issues of loss or abandonment in your childhood? -If so, do you see that issue causing some problems in your relationship with a child?

COMMUNICATION

-How did verbal communication differ from each of your parents toward you?

-Did either of your parents understand your feelings? Please explain.

-How did communication progress during the teenage years?

-Did either parent use: (please indicate which parent and to what excess)

-Disapproval?

-Withdrawal?

-Threats of physical punishment?

-Threats of abandonment?

-Hitting or spanking?

-Verbal criticism?

-Did actions (good or bad) show your feelings to your parents better than words? Please describe.

-In what ways, if any, has your communication process changed from that of your parents? If change has occurred, what caused this change?