Attachment Disorder Treatment

Father Employed by_____________________________________________

Business Telephone_____________________________________________

Soc. Sec. #_____________________________________________________

Mother Employed by_____________________________________________

Business Telephone_____________________________________________

Soc. Sec. #____________________________________________________

Family Physician_________________________________

Referred by_____________________________________

Telephone#___________________

Chief Complaint & Problem___________________________________________

__________________________________________________

Is Child Adopted?________________________

If So, At What Age?______________________

Child's First Name Prior to Adoption__________________________

Complications of Birth & Delivery____________________________

_______________________________________________________

Have there been any physical or emotional separations (i.e. death, hospitalizations, depression)
between child and caretaking adult during the first 26 months of life?________________________________________________________________________

Is there, as far as you know, any possible history that could be considered abusive? If so,
indicate type(s) and age of occurrence. __________________________________________ _______________________________________________________________________________

If it is hard to remember ages, please simply check the problem areas or areas you feel were/are advanced or slow in development.

Name of Child___________________	Birthdate_____________________
Parent's name
(Father)________________________	DOB__________________________
(Mother)_______________________	DOB__________________________

Address________________________
___________________
Telephone
(Daytime)______________________	(Evening)_____________________
Level of Education
(Father)________________________
(Mother)_______________________
(School of Child_________________	Grade________________________
Others living at home:

Age he/she:	Does he/she:	Is he/she:
held head up __________	have blank spells __________	shy or timid __________
crawled __________	rock __________	affectionate __________
walked with help __________	shuns attention __________	well coordinated __________
used sentences __________	have temper tantrums __________	impulsive __________
fed self __________	have falling spells __________	stubborn __________
dressed alone __________	have unusual fears __________	right/left handed __________
turned over __________	bump head __________	clumsy __________
sat __________	hold breath __________
walked alone __________	show dare devil behavior __________
was weaned __________	have sleep problems __________
said "no, no" to everything __________	have eating problems __________
smiled at parents __________
pull up at crib __________
said 4-10 words __________
helped with dressing __________
dry during day __________
dry during night __________


Name	Sex	Birth date	Age	School/Grade
___________	____	___________	_____	___________
___________	____	___________	_____	___________
___________	____	___________	_____	___________
___________	____	___________	_____	___________