Child Behavioral Health Assessment Form
Child Information
Child's Name
Date of Birth
Age
Gender
Male
Female
Other
Prefer not to say
Guardian Information
Guardian's Name
Relationship to Child
Contact Number
Reason for Assessment
Please describe the reason for this assessment
Behavioral Concerns
List or describe observed behavioral concerns
Developmental History
Summarize key developmental milestones, delays, or medical history
Social & Family Information
Briefly describe family environment and social relationships
School/Academic Information
Current school and grade
Any academic or learning challenges?
Additional Notes
Other comments or relevant information