The UF Behavioral Health Mental Health Background Information form asks for the following:
DEMOGRAPHICS
- Name of the person completing this form
- Relationship to the child
- Phone number
- Email address
- Child’s full legal name
- Child prefers being called
- Child’s Date of Birth
- Age
- Gender
- Race
- Ethnicity
- Religion
- Child’s Primary Care Provider
- Please list who lives in the same household as the child (include name, sex, age, and relationship to child)
PSYCHIATRIC HISTORY
- What are the main concerns that you have about the child’s behavior or emotions?
- How long have you had these concerns?
- For these questions, answer No or Yes, and if Yes, please describe/specify
- Has the child ever attempted suicide?
- Does the child engage in any self-harm behaviors (like cutting)?
- Has the child ever been violent?
- Has the child ever been aggressive?
- Does the child use alcohol?
- Does the child use tobacco or vape?
- Does the child use illegal drugs?
- Has the child ever seen a psychiatrist or therapist/counselor before? If yes, please include the name(s) of provider(s), dates, and reason.
- Has the child ever been admitted to a psychiatric hospital? If yes, please include the name(s) of the hospital(s), dates, and reason.
FAMILY HISTORY
- Please identify any known psychiatric illnesses in blood relatives of the child (specify if Child’s Mother, Child’s Father, Child’s siblings, Mother’s side of the family, or Father’s side of the family)
- Anxiety
- Attention-deficit/hyperactivity disorder (ADHD)
- Autism
- Bipolar disorder
- Depression
- Eating disorder
- Intellectual disability or learning problems
- Psychosis
- Schizophrenia
- Substance/alcohol/drug misuse
- Suicide
MEDICAL HISTORY
- Does your child have any history of the following medical conditions? (select all that apply)
- Allergies (describe)
- Asthma
- Blood Pressure – High
- Blood Pressure – Low
- Convulsions/Seizures/Epilepsy
- Diabetes
- Dizziness or Fainting
- Head Injury
- Hearing Problems
- Heart Problems
- Loss of Consciousness
- Respiratory Illness
- Urogenital Problems
- Vision Problems
- Please list any other serious illness or disease
- If your child has had surgery, please describe and give dates
- If your child has had any serious injuries, please describe and give dates
- Biological females only, if your child has started menstruation, at what age? Are periods regular?
MEDICATIONS
- Please list all medication the child is currently taking (include name of medication, dose of medication, and who prescribes it)
- Please list any medications the child has taken in the past
- Please list any drug allergies
SOCIAL HISTORY
- Name of current school
- Current grade
- Did the child repeat any grades?
- Does the child have a 504 plan or IEP?
- Is the child in ESE or special needs classes?
- Please list any school problems (behavioral or academic)
DEVELOPMENTAL HISTORY
- Has anything significant occurred during the child’s development years? (delays, not meeting milestones, etc.)
TESTING HISTORY
- Any history of IQ or achievement testing?
- Ever been tested for hearing abnormalities?
- Ever been tested for speech/ language abnormalities?
- Has the child ever received occupational or physical therapy?
OTHER
- Has the child experienced any of the following, answer No or Yes, and if Yes, please describe/specify
- Adoption (if yes, are they aware?)
- Conflicts with parents
- Death of a parent, loved one, close friend
- Family financial problems
- Foster care/removal of child from home
- Illness in family
- Loss of home
- Other separation from parent/family
- Parent separation/divorce
- Unwanted pregnancy
- Victim of crime or violence
- Other
- Please elaborate on any of the above and how they have affected the child, any symptoms as a result
To request a printable version of the above, please email us at PSYCH-UFBHH@ad.ufl.edu