Biopsychosocial Assessment Page 3
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10For Psychologist Use Only
Presenting Problem / History of Problem:
Symptoms:
Interview / Observation of child:
SOCIAL AND BEHAVIOR CHECKLIST
Place a check next to any behavior or problem that your child currently exhibits.
____ Has difficulty with speech
____ Has frequent tantrums
____ Has difficulty with hearing
____ Has frequent nightmares
____ Has difficulty with language
____ Has trouble sleeping (describe) _______________
____ Has difficulty with vision
____ Has blank staring spells
____ Has difficulty with coordination
____ Rocks back and forth
____ Prefers to be alone
____ Bangs head
____ Does not get along well with other children
____ Holds breath
____ Is aggressive
____ Eats poorly
____ Is shy or timid
____ Is stubborn
____ Has poor bowel control (soils self)
____ Is much too active
____ Is more interested in things (objects) than in people
____ Engages in behavior that could be dangerous to self (describe) ______________________________
Describe child’s relationship with his / her:
Father _______________________________________________________________________________
Mother _______________________________________________________________________________
Sibling(s)______________________________________________________________________________
Step parent(s) _________________________________________________________________________
OTHER INTERPERSONAL RELATIONSHIPS:
How do you describe the child’s friendships:
No Friends Only Acquaintances Both acquaintances and close friends
How many close friends? __________
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