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Please rate your child in the following areas: <br /> Attendance Cognitive Ability Relatidns with peers Behavior in school <br /> El rarely absent El above average ❑ above average El above average <br /> ❑sometimes absent ❑average ❑ average ❑average <br /> ❑ often absent ❑ below average ❑ below average ❑ below average <br /> Has your child been involved in any type of therapy or counseling in the past individual,family,groups)? <br /> Has your child ever been prescribed psychiatric medication(antidepressant,ADD medication,etc.)? ❑Yes ❑ No If yes, please list <br /> medication and when and why your child takes them as well as who prescribes the medication. Or have any been recommended? <br /> Have any family members had the following? If so,what is their relationship your child? <br /> ❑ Depression: <br /> ❑ _ <br /> Anxiety: <br /> El ____-.._._—. _._.._..—__ — _—.____�____...._._... <br /> ❑ Eating Disorder: -----------_________ <br /> ❑ Bipolar Disorder/Manic-depression: <br /> _ <br /> ❑ Obsessive-compulsive Disorder: --- - --------______ ____.___ <br /> ❑ Alcohol/drug problems: <br /> • <br /> ❑ Suicide attempts: <br /> ❑ Psychiatric Hospitalizations: <br /> ❑ Other mental health/psychiatric problems(please specify): <br /> IS THERE AN c,EL-st roU-WO LD LIKE THE THERAPIST TO KNOW ABOUT YOUR CHILD OR FAMILY? PLEASE ADD <br /> ANY FURTHER COMMENTS OR CONCERNS. <br /> This form was completed by: Date: <br /> (Please print first and last name) <br /> Page 3 of 3 <br /> 1fl , <br />