Family Medical and Behavioral Interview

Date of Interview / Form Completion

Your First Name

Your Last Name

Your Relationship to the Client

Your Email

Your Phone Number

Client's First Name

Client's Last Name

Date of Birth

Gender (optional)

Reason for Referral

Primary Language

Other Language Spoken

Living Arrangement (Please describe your home and community)

Where does the client reside?

Family Home

Foster Home

Group Based Home/Facility

Other

Address (if different than Family Home)

Address Line 1

Address Line 2

City

State

Zip Code

Country

First Name

Last Name

Relationship

Phone/Mobile

First Name

Last Name

Relationship

Phone/Mobile

First Name

Last Name

Relationship

Phone/Mobile

First Name

Last Name

Relationship

Phone/Mobile

Alternate Address

Parent/Caregiver Status

Married

Divorced

Separated

Single

Legal Guardian

Other

Who is responsible for medical/behavioral health decisions?

Joint

Sole

If sole custody, specify which parent

With whom does the child reside?

Are both parents aware of the MDA services?

If no, list reason

Household 1 - Name of Parent/Guardian

Household 1 - % of Time in Household

Household 1 - Other Individual 1 Name

Household 1 - Other Individual 1 Age

Household 1 - Other Individual 1 Relation to Client

Household 2 - Name of Parent/Guardian

Household 2 - % of Time in Household

Household 2 - Other Individual 1 Name

Household 2 - Other Individual 1 Age

Household 2 - Other Individual 1 Relation to Client

Does the client have a Guardian Ad Litem?

Yes

Guardian Ad Litem Name

Guardian Ad Litem Phone

Guardian Ad Litem Email

Legal Status of Client (obtain legal documentation from parent/guardian if applicable)

Are educational reports available?

IEP

504 Plan

School Evaluation

Behavior Plan

Is the loved one currently receiving school-based services?

Yes

School Service 1 - Type

School Service 1 - Location

School Service 1 - Start Date

School Service 1 - End Date

School Service 1 - Intensity/Week

School Service 1 - Day(s) of Service

School Service 2 - Type

School Service 2 - Location

School Service 2 - Start Date

School Service 2 - End Date

School Service 2 - Intensity/Week

School Service 2 - Day(s) of Service

Is the loved one currently receiving community-based services?

Yes

Community Service 1 - Type

Community Service 1 - Location

Community Service 1 - Start Date

Community Service 1 - Ends On

Community Service 1 - Intensity/Week

Community Service 1 - Day(s) of Service

Community Service 2 - Type

Community Service 2 - Location

Community Service 2 - Start Date

Community Service 2 - Ends On

Community Service 2 - Intensity/Week

Community Service 2 - Day(s) of Service

Community Service 3 - Type

Community Service 3 - Location

Community Service 3 - Start Date

Community Service 3 - Ends On

Community Service 3 - Intensity/Week

Community Service 3 - Day(s) of Service

Reports Available (Community-Based)

Psychological

Family Support Plan

Individual Support Plan

Previous Intervention 1 - Provider Name

Previous Intervention 1 - Service Provided

Previous Intervention 1 - Service Level (e.g. 60 min/week)

Previous Intervention 1 - Reason for Termination

Previous Intervention 1 - Start Date

Previous Intervention 1 - End Date

Previous Intervention 2 - Provider Name

Previous Intervention 2 - Service Provided

Previous Intervention 2 - Service Level (e.g. 60 min/week)

Previous Intervention 2 - Reason for Termination

Previous Intervention 2 - Start Date

Previous Intervention 2 - End Date

Reports Available (Previous Interventions)

Behavior Plan

Treatment Plan

Other

Reports Available - Other (specify)

Response to Treatment Provided (goals worked on, what worked, what didn't)

Previous Interventions - General Notes

Progress or recent changes / goals for 6 months, 1 year, 5 years

Mother's health issues during pregnancy?

Yes

Explanation

Any unusual circumstances at birth?

Yes

Explanation

Developmental Delays

Motor

Speech

Social

Intellectual

Academic

Describe developmental history

Are there any motor development concerns (movement, coordination, strength, endurance)?

Yes

Explanation

Sensory differences (vision, hearing, smell, taste, or touch)?

Yes

Sensory Differences - Explanation

Hours of sleep daily, including naps

Does the child sleep through the night?

Yes

Eating Habits/Dietary Restrictions and behavioral impact

Family Changes and how they have affected the loved one

Suicidal or Homicidal Ideation - if yes, refer for immediate evaluation or call 911

Yes

Has your loved one been a victim of abuse of any kind?

Yes

Has your loved one been a perpetrator of abuse of any kind?

Yes

Abuse History Details

Sexual Behavior History applicable?

Yes

Details of Sexual Behavior

Past or current substance abuse (including nicotine and alcohol)

Has any substance abuse screening occurred?

Yes

Substance Abuse Screening - Description

Is your loved one under Department of Corrections (DOC) supervision?

Yes

Under civil or criminal court-ordered mental health or substance use disorder treatment?

Yes

Court order exempting from reporting requirements? (copy of court order required if yes)

Yes

WAC 246-341-0640 Compliance - Additional Explanation

Department of Corrections or Court-Ordered Treatments (summary)

DOC Supervision

Court-Ordered MH/SUD Treatment

Court Order Exemption from Reporting

Diagnosis 1 - Name

Diagnosis 1 - Date

Diagnosis 1 - Physician

Diagnosis 2 - Name

Diagnosis 2 - Date

Diagnosis 2 - Physician

Diagnosis 3 - Name

Diagnosis 3 - Date

Diagnosis 3 - Physician

Allergies

Frequent colds, ear infections or other illnesses?

Yes

Frequent Illness - List

Frequent Illness - How Frequent

Additional medical complications affecting behavior (asthma, skin conditions, stomach problems, seizures, etc.)

Currently under a doctor's care for any medical condition?

Yes

Doctor's Phone

Doctor's Practice

Doctor's Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Medication 1 - Name

Medication 1 - Dosage (e.g. 1 mg daily)

Medication 1 - Physician

Medication 1 - Purpose

Medication 1 - Possible Common Side Effects

Medication 2 - Name

Medication 2 - Dosage (e.g. 1 mg daily)

Medication 2 - Physician

Medication 2 - Purpose

Medication 2 - Possible Common Side Effects

Family History of Conditions (check all that apply)

Hearing Loss

Speech Deficits/Delays

Educational Barriers or additional limitations

Attention Disorders

Seizure Disorder

Drug Use

Delayed Motor Development

Mental Illness

Other

List whom and how/if it could affect behavior, implementation, participation

Relevant spiritual variables (family beliefs, perspectives, rituals, observations, traditions)

First Name

Last Name

Relation to Client

Caregiver Signature (type full name to sign)

Date Signed (Caregiver)

Provider Name with Credentials

Provider Signature (type full name to sign)

Provider Signature Date

First Name

Last Name

Family Medical and Behavioral Interview

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