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Psychiatry FAMILY QUESTIONNAIRE TO BE COMPLETED BY PARENT (Kaiser Permanente)

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01996-110 (05-19)
Psychiatry
Northern California
FAMILY QUESTIONNAIRE
MR #:
Name:
IMPRINT AREA
TO BE COMPLETED BY PARENT OR LEGAL GUARDIAN.
CHILD / TEEN’S PREFERRED NAME ETHNICIT Y GENDER AGE
ADDRESS (STREET, CITY, ZIP CODE)
PERSON COMPLETING FORM LEGAL GUARDIAN?
Yes
No
PRIMARY CAREGIVER’S NAME RELATIONSHIP TO CHILD BEST CONTACT NUMBER
PRIMARY CAREGIVER’S NAME RELATIONSHIP TO CHILD BEST CONTACT NUMBER
BIOLOGICAL PARENT’S NAME (IF DIFFERENT FROM ABOVE)
REFERRAL SOURCE
Self
Primary Care Provider
Other: __________________________________________________
RELIGION
SCHOOL NAME SCHOOL GRADE
ALL INDIVIDUALS WHO CURRENTLY LIVE WITH THE CHILD INCLUDING PARENTS/CAREGIVERS:
(PLEASE DENOTE IF SEPARATE HOUSEHOLDS)
NAME
AGE
RE
LATIONSHIP
OCCUPATION /
SCHOOL GRADE
CHILD’S MAIN PROBLEM / MAJOR REASONS FOR SEEKING HELP AND WHEN THESE CONCERNS BEGAN:
PAGE 1 OF 7
01996-110 (05-19)
MR #:
Psychiatry
Northern California
Name:
Please check the items below that are signicant current problems for your child/teen.
Is it hard for your child to focus and pay attention?
No (skip to next section)
Yes (complete items below)
Make careless mistakes or does not pay attention to details
Problems paying attention/staying focused
Avoids, dislikes, or is reluctant to complete tasks that
require sustained mental eort (homework, chores)
Problems with organization
Lose things easily
Forgetful
Easily distracted
Does not listen when spoken to directly
Does not follow through on instructions or work
Does your child have a hard time controlling their words
or behaviors?
No (skip to next section) Ye
s (complete items below)
Fidgets with hands or feet or squirms in seat
Leaves classroom or other seat inappropriately
Excessively runs about, climbs, or is restless
Diculty p
laying q
uietly
Always “on the go”
Talks excessively
Blurts out answers to questions
Diculty a
waiting t
urn
Interrupts or intrudes on others
Is y
our child feeling sad, depressed, or irritable?
No (skip to next section)
Yes (complete items below)
Depressed or irritable mood much of the time
Problems sleeping
Fatigue or loss of energy
Decreased interest or pleasure in activities
Increased/decreased appetite
Increased/decreased physical activity
Feeling worthless or excessively guilty
Problems thinking, concentrating, or being indecisive
Is your child often worried or anxious?
No (skip to next section)
Yes (complete items below)
Excessive anxiety or worry (about past behaviors,
future events, competence)
Phobia or extreme fear
Excessive fear of social situations or public speaking
Avoids social situations or public speaking
Avoids or refuses to go to school
Persistent worry about harm to family members
Excessive distress when separated from family
Persistent refusal to sleep alone
Repeated nightmares about separation from family
Repeating behaviors (e.g., counting, washing)
Is your child often angry at others?
No (skip to next section)
Yes (complete items below)
Blame others for my mistakes
Angry most of the time
Easily annoyed by others
Go against adult requests or rules
Back talk or argue with adults
Deliberately annoys people
Lose temper
Desire to hurt others or get revenge
PAGE 2 OF 7
Has your child experienced or witnessed a traumatic event
(i
.e., car, accident, death, earthquake)?
No (skip to next section) Ye
s (complete items below)
Ongoing negative thoughts about what happened
Ongoing negative feelings about what happened
Recurrent distressing dreams about the event
Flashbacks about the event
Attempts to avoid memories, thoughts, or feelings about
w
ha
t happened
01996-110 (05-19)
MR #:
Psychiatry
Northern California
Name:
Does your child do things that get them into trouble?
No (skip to next section)
Yes (complete items below)
Bully or threaten others
Get in physical ghts
Hurt animals
Stole things
Set a re
Destroyed property
Broke into a house, building, car
Stay out all night
Ran away
Truant from school
Problems with the law or police
Used an object as a weapon
Lies to obtain goods/favors or avoid obligations
Does your child have a problem with eating or body image?
No (skip to next section)
Yes (complete items below)
Fear of weight gain or being fat
Trying to lose weight
Unhappy with body weight or shape
Purging/self-induced vomiting
Use of diet pills, laxatives, excessive exercise
Overeat/binge
Excessively restricts food intake
Does your child have excessive mood or aggressive
behavior problems?
No (skip to next section)
Yes (complete items below)
Excessive mood swings
Racing thoughts
Aggressive behavior
Chronic irritability
Violent nightmares
Explosive temper outbursts (verbal or physical)
D
oes your child have periods of extreme panic or fear?
No (
skip to next section) Yes (complete items below)
Palpitations, pounding heart, accelerating heart rate
Sweating
Trembling or shaking
Sensations of shortness of breath
Nausea/abdominal distress
Feeling dizzy, unsteady, lightheaded, faint
Chills or heat sensations
Fear of dying
Constant worry of panic sensations returning
Does your child have any RISK or SAFETY concerns?
No (skip to next section)
Yes (complete items below)
Self-injury (e.g., cutting, burning)
Thoughts of death or suicide
Suicide attempt
Thoughts of harming or killing others
Hearing voices or seeing things that are not there
Does your child have social or developmental problems?
No (
skip to next section) Yes (complete items below)
Problems responding to or interacting with others
Problems understanding or lack of nonverbal gestures
Poor eye contact
Problems developing and maintaining relationships
Lack of interest in other children
Repetitive motor movements
Overreacts to changes in routine
Extremely restricted interest or activities
Reacts excessively to noise, touch, or texture
D
oes your child have any additional concerns?
No (skip to next section)
Yes (complete items below)
Motor or vocal tics
Repeated urination in bed or clothes
Repeated stool holding or soiling
Other:
PAGE 3 OF 7
01996-110 (05-19)
MR #:
Psychiatry
Northern California
Name:
CHILD’S PREVIOUS TREATMENT
None
Individual Therapy
Psychiatry (medication)
Group Therapy
Family Therapy
Inpatient
ABA
Residential (overnight)
IF ANY, PLEASE SPECIFY THE TREATMENT FOCUS AND PROVIDER(S):
Please describe current or past abuse.
CHILD ABUSE
WITNESSED VIOLENCE AT HOME
DATING VIOLENCE
PEER VIOLENCE (bullying)
ONLINE VIOLENCE (sexting, cyber-bullying)
None Verbal
(put downs,
controlling)
Physical
(hits, threatens
to hit)
Sexual
(pressured or
forced)
DEVELOPMENTAL AND MEDICAL HISTORY
PREGNANCY, LABOR, DELIVERY PROBLEMS:
None
Yes:
CHILD EXPOSURE DURING PREGNANCY
None
Alcohol
Drugs
Tobacc o
Accident
Illness
DELAYS IN DEVELOPMENTAL MILESTONES
None
Talking
Walking
Toilet training
Specify:
BABY/INFANT BEHAVIOR
Ate well
Easy to soothe
Wanted to be left alone
Colicky
Easy to regulate (sleep, eat)
Dare-devil behavior
Clumsy
Adaptable to transitions
Head banging
Other:
MEDICAL PROBLEMS
Allergies
Operations
Convulsions
Asthma
Poisoning
Bladder / bowel problems
Head injury
Serious infection
Ear infections
Other:
PAGE 4 OF 7
01996-110 (05-19)
MR #:
Psychiatry
Northern California
Name:
CURRENT MEDICATIONS:
CURRENT SUPPLEMENTS, VITAMINS, AND HERBAL REMEDIES: ____________________________________________
EXERCISE PER DAY (average) 0 30 mins. 1– 2 hrs. 3 hrs. or more
MEDIA USE PER DAY (average hours)
(e.g., video games, phone, computer, television)
0 1– 2 3–4 5 or more
CAFFEINE DRINKS PER DAY
(
e.g., coee, soda, energy drinks)
0 1– 2 3–4 5 or more
SLEEP PER NIGHT (average hours)
less than 5
6–7
8–10
11–12
PSY
CHOSOCIAL HISTORY
MA
RITAL PROBLEMS
DIVORCE/SEPARATION
CUSTODY DISPUTES
FINANCIAL PROBLEMS
HOUSING PROBLEMS
Current Past
DEATH OF A LOVED ONE
SERIOUS FAMILY ILLNESS
PARENT ALCOHOL/DRUG USE
JOB LOSS
PARENT INCARCERATION
Current Past
SOCIAL SKILLS WITH PEERS
Poor
Average
Good
Unknown
BEHAVIOR WITH SIBLINGS
Poor
Average
Good
N/A
BEHAVIOR WITH PARENTS / GUARDIANS
Poor
Average
Good
Unknown
JUVENILE JUSTICE INVOLVEMENT
No
Yes:
DISCIPLINE STRATEGIES
Helpful most of the time
Not helpful most of the time
Verbal reprimands / discussions
Remove privileges
Physical punishment
Time out
Grounding
Reward
/ incentives
PAGE 5 OF 7
01996-110 (05-19)
______________________________________________________________
MR #:
Psychiatry
Northern California
Name:
Please check who of the child’s biological family members had these conditions in the past or present.
Please specify other biological relatives (aunt, uncle, grandparent) in the others column.
MOTHER FATHER OTHERS (siblings, aunt,
uncle, grandparent)
MATERNAL PATERNAL
Childhood inattention, over-activity, or poor impulse control
Learning disabilities
Developmental delays or Autism Spectrum Disorders
Schizophrenia or psychosis
Depression (2+ weeks), mood swings, or bipolar disorder
Suicide attempts or completion
Anxiety or OCD
Tics/Tourette’s
Alcohol or drug abuse
Antisocial (assaults to family and others, thefts, arrests)
EDUCATIONAL HISTORY
ACADEMIC PERFORMANCE
Poor Average Above Average Unknown
ATTITUDE TOWARDS SCHOOL
Poor Average Above Average Unknown
ACADEMIC SERVICES
Home and hospital
Occupational therapy
Independent study
Gifted program
Speech therapy
Resource classes/Special education
504 Plan
Individualized Education Plan (IEP)
SCHOOL PROBLEMS
Learning problems:
Works hard, but does not do well
Repeated grade (Grade: )
Frequent discipline referrals or detention
Suspensions/expulsions (#: )
Other school problems:
PAGE 6 OF 7
MR #:
X Psychiatry
Northern California
Name:
CHILD, ADOLESCENT, AND FAMILY DATA
IMPRINT AREA
ENCOUNTER DATE
DESCRIBE THE IMPACT OF YOUR CHILD’S PROBLEMS ON THE FAMILY:
DESCRIBE YOUR CHILD’S STRENGTHS AND UNIQUE QUALITIES:
DESCRIBE YOUR FAMILY STRENGTHS AND SUPPORTS (e.g., friends, spiritual and cultural considerations):
WHAT ARE YOU HOPING TO GET OUT OF BEING HERE (e.g., improve child’s mood, help with anger, work on relationships)?
HOW IMPORTANT IS THIS CHANGE FOR YOU? (Please circle a number.)
Not at all Completely
0 1 2 3 4 5 6 7 8 9 10
01996-110 (05-19) PAGE 7 OF 7
KPNC’s Mental Health and Chemical
Dependency Services: Your Right to Privacy
Confi dentiality Disclosure
X Psychiatry
MR #:
Name:
Kaiser Permanente’s Mental Health and Chemical Dependency (MH/CD) Program is strongly committed to protecting
your privacy. The Northern California Notice of Privacy provides general information about how your medical informa-
tion is used and protected. Federal law protects the confidentiality of chemical dependency records. See 42 U.S.C.
290dd-3 and 42 U.S.C. 290ee-3 for federal laws and 42 CFR part 2 for federal regulations. Violation of federal confi -
dentiality laws related to chemical dependency programs is a crime. Suspected violations may be reported to the ap-
propriate authorities. The Department of Justice jurisdiction for Northern California includes the Eastern and Northern
District Attorney’s Offices. The contact information for each district can be found here: https://www.justice.gov/usao/
find-your-united-states-attorney and is also listed below: Eastern District, 501 I Street, Suite 10-100, Sacramento, CA
95814, 916-554-2700 (phone), 916-554-2900 (fax); Northern District, Heritage Bank Building, 150 Almaden Blvd. Suite
900, San Jose, CA 95113, Phone: 408-535-5061 Fax: 408-535-5066. Your written authorization is required before any
information about chemical dependency treatment can be disclosed to anyone outside the Department of Psychiatry,
subject to certain exceptions permitted by law.
Coordination of Care
At Kaiser Permanente, Mental Health and Chemical Dependency services are considered one Program and operate
under the Department of Psychiatry. Any MH/CD information can be shared between Mental Health staff and Chemi-
cal Dependency staff without your written consent. Regulations pertaining to mental health patient information and
chemical dependency patient information are as follows:
Patients Receiving Only Mental Health Care: For mental health care, your permission is not required to coordinate
your care with other providers, such as your primary care physician. When coordinating your care, we will only share
information that, in our professional judgment, is needed for appropriate medical care by that provider. Mental Health
diagnoses and appointment dates are available to your other treating providers on a need-to-know basis. Generally,
we will discuss any necessary sharing of other mental health information with you.
Patients Receiving Chemical Dependency Care: For chemical dependency care (which would include mental
health care that is part of your chemical dependency care), your written authorization is required before any informa-
tion about chemical dependency treatment can be disclosed to anyone outside the Department of Psychiatry.
Exceptions to Confi dentiality Rules
The law authorizes us to disclose limited information about your treatment in the MH/CD Program without your
consent, to certain persons and in certain circumstances:
•
In medical and psychiatric emergencies in which the information is essential to an individual’s safety.
•
To qualified personnel for audit, program evaluation, or research.
•
For reporting of suspected child abuse or neglect.
•
To report the commission of crimes on our premises or against our program personnel.
•
In response to court orders that comply with the standards for the type of record covered by the order.
•
To other Kaiser Permanente departments who provide administrative and clinical support to the MH/CD
Program and which have agreed to abide by the federal chemical dependency confi dentiality rules.
If, at any time, you have concerns about your privacy, you are encouraged to request clarification from your thera-
pist or a staff member.
02150005 (1117)
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Psychiatry FAMILY QUESTIONNAIRE TO BE COMPLETED BY PARENT (Kaiser Permanente)

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Completed 28 January 2022

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