Client Initials/Chart Number:
Date of Evaluation:
Privileged & Confidential
Child & Adolescent Diagnostic Interview
Identifying Information:
Name: Languages:
DOB/Age: School/Grade:
Gender: Religion/Spirituality:
Place of Birth: Currently living with:
Adopted: ☐ Yes ☐ No (include age & occupation):
Parents:
☐ Married ☐ Never Married
☐ Divorced ☐ Living in Separate Homes
☐ Separated
Referral Source:
Presenting Complaint:
Presenting Symptoms:
☐ Depressed Mood ☐ Low Self-Esteem ☐ Weight Gain/Loss
☐ Difficulty Concentrating ☐ Tearfulness ☐ Anxiety
☐ Difficulty Sleeping ☐ Restlessness ☐ Mania/Hypomania
☐ Insomnia ☐ Tension ☐ Flight Of Ideas
☐ Hypersomnia ☐ Angry Outbursts ☐ Panic Attacks
☐ Loss Of Energy ☐ Irritability ☐ Substance Use
☐ Loss Of Interest ☐ Aggression/Defiance ☐ Self-Harm
History of Present Illness:
When did symptoms start? (identify date, duration, and frequency)
Identify any major life stressors and/or events?
Prior Psychiatric History: (have they ever received any therapeutic services including speech, occupational,
physical, or psychotherapy? List name of therapist(s)/agency, start dates, frequency, and reasoning)
Any prior psychiatric hospitalizations? If so, how many? Reasoning?
Name of Psychiatrist? Last visit?
Any prior psychiatric diagnosis?
Any prescribed psychotropic medications? (include name, dosage, frequency, potential side-effects)
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Prior Assessment History: (any previous intelligence, personality, or psychological testing)
Medical History: (any medical conditions, diagnosis, concerns, allergies or previous surgeries?)
Medications: (include name of dosage, frequency, date prescribed, length of time taken, and benefits/side effects)
Name of primary care physician and when was their last physical examination? Any concerning findings?
Any history of head trauma, loss of consciousness, or seizures?
Do they smoke (cigarettes, cigars, vapes) or drink caffeine?
History of Substance Abuse: (current and past substance use (age at first use, frequency, duration) and identify
any treatment).
Legal History: (any charges, arrests, or time spent incarcerated)
Family Psychiatric & Substance Abuse History: (any significant familial psychiatric history, including any
diagnosis, hospitalizations, suicide attempts, completed suicide, therapy, or substance abuse?)
Family History of Medical Conditions: (diabetes, high blood pressure, or cancer, etc.)
Psychosocial History: (explore family dynamics, sources of support, briefly describing parent’s occupation,
positive or difficulties with certain members in household to describe quality).
Mother’s Work:
Father’s Work:
Grandparent’s:
Any siblings?
How many friends?
Do they prefer to play alone or with others?
Well behaved at home? At school?
Hobbies/Activities:
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Educational History:
Name of school?
Grade?
What are their grades like?
● Reading:
● Writing/Spelling:
● Math:
● Attention:
Have they ever repeated a grade?
Any tutoring, IEP, or special services?
Detentions, Suspensions, Expulsions?
Developmental History:
How was the mother's/patient’s pregnancy?
Full-term or Premature?
Any medical complications?
Did they meet all developmental milestones within normal limits?
Gross motor: Walk? Talk? Running? Jumping? Sitting upright?
Fine motor: precision/accuracy (i.e., holding pencil/writing, using scissors, tying shoes, brushing teeth, holding
utensils, buttoning shirts, turning book pages etc.)
History of Abuse: any history of physical, sexual, emotional abuse or neglect? (Was it reported? If so, what is the
DCF/police case number? When did it occur, who was involved, and what occurred?)
Any traumatic events?
Any exposure to domestic violence?
Mental Status: general appearance, hygiene, behavior, attitude toward clinician, reliability of information they
provide, alertness, orientation, speech, eye-contact, mood, affect, thoughts process/content, judgement, insight,
suicidality, homicidality, self-harm, non-suicidal self-injurious behaviors, psychosis (auditory, visual, tactile,
olfactory), delusions?
Identification of Risk & Protective Factors:
Measures Given: (if needed, were any interventions provided?)
BDI:
BAI:
PHQ-9:
GAD-7:
WAIS:
WISC:
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Identifying Triggers/Coping Skills:
Diagnostic Summary: (name, demographics, reason for referral, presenting symptoms, stressors/timeline)
Primary Diagnosis:
Treatment Plan/Recommendations: (recommend procedures for diagnostic clarification, including referrals to
other health professionals, plan of interventions, identify appropriate level of severity for outpatient, residential,
crisis settings).
Recommendations: (to parents, school staff, psychiatrist, or care team)
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