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HolistiCare, LLC - Child & Adolescent Collateral Form

Parent, Caregiver, Relative & Teacher Developmental and Behavioral Questionnaire

SECURITY NOTICE: To protect privacy, please DO NOT enter the child's name or your own full name anywhere on this form. Only use the Patient ID provided to you.

IMPORTANT INSTRUCTION: Children and adolescents often express emotional, behavioral, or neurodevelopmental challenges differently across settings (such as home vs. school) and through physical complaints (such as stomachaches or headaches). Please check any symptoms you have observed at ANY point across the child's entire life—whether in early childhood or happening right now—and indicate the timing at the bottom of each section.

Informant & Observation Context

Patient ID (Required - Do NOT enter child's name) *

✓ Patient ID pre-filled from secure link. Edit ID

Child's Current Age & School Grade *

Your Relationship to the Child *

Please Specify Your Role (No Personal Names)

Primary Setting Where You Observe the Child *

How long have you known or worked with this child?

In your own words, what are your top concerns for this child right now, and what are their greatest strengths?

1. Early Development, Infancy & Milestones

If you are a teacher or did not know the child during infancy/toddlerhood, you may select "None observed / Unknown to me" below.

Pregnancy or birth complications (prematurity, NICU stay, low birth weight, fetal distress, or maternal health complications) Difficult infancy temperament (extreme colic, inconsolable crying, difficulty being soothed, or severe early feeding/sleeping problems) Delayed speech or language milestones (late to babble, speak single words by 12–15 months, or combine phrases by age 2; needed speech therapy) Delayed gross or fine motor milestones (late sitting, crawling, walking, or difficulty holding utensils/crayons; needed OT/PT) Developmental Regression: Appeared to learn words, social skills, or motor/toileting skills and then noticeably lost them Received Early Intervention (Birth-to-3), developmental preschool services, or early occupational/speech/physical therapy None observed / Unknown to me (e.g., Teacher or met child later in life)

2. Neurodevelopmental: Attention, Executive Function & Hyperactivity

Please check any behaviors that occur more frequently or severely than expected for a child of the same age.

Inattention & Executive Functioning

Makes careless mistakes in schoolwork or chores; misses key details or rushes through tasks Struggles to keep attention on routine tasks, classroom instruction, or reading (even if they can "hyperfocus" for hours on video games, Legos, or preferred topics) Often seems not to listen when spoken to directly; stares off, daydreams, or appears "in their own world" Struggles with multi-step directions (e.g., if asked to "put on shoes, grab your backpack, and brush teeth," forgets after step one) Chronic disorganization (messy backpack/desk/room; completes homework at home but loses it or forgets to turn it in at school) Strongly avoids, procrastinates, or has meltdowns over tasks requiring sustained mental effort (homework, reading, writing paragraphs) Frequently loses everyday items needed for daily life (jackets, water bottles, lunchboxes, books, pencils, glasses, retainers) "Time blindness" — poor awareness of how much time has passed, chronically slow getting ready in the morning or transitioning between activities

Hyperactivity & Impulsivity

Fidgets constantly with hands or feet, squirms in seat, rocks, or chews on pencils/shirt collars Leaves seat in the classroom, at the dinner table, or in other situations where sitting is expected Runs about or climbs on furniture/objects in inappropriate situations (in teens: reports feeling constantly restless or jittery inside) Often "on the go," acts as if "driven by a motor," or has trouble playing/relaxing quietly Talks excessively, makes repetitive noises/sound effects, or blurts out answers before a question is completed Struggles to wait their turn in games or lines; frequently interrupts, intrudes on others' conversations, or grabs items without thinking Acts without thinking about physical danger (darting into parking lots, climbing dangerously high, reckless biking/driving)

Timing for Attention & Hyperactivity Symptoms:

Past Only (Earlier childhood, resolved now) Current Only (Recent onset) Both Past & Current (Lifelong / Ongoing) None / N/A

3. Neurodevelopmental: Social Communication, Flexibility & Sensory Processing

Evaluates social reciprocity, pragmatic communication, behavioral rigidity, and sensory sensitivities across development.

Social Communication & Peer Interaction

Reduced, fleeting, or unusual eye contact; struggles to read other people's facial expressions, tone of voice, or body language Struggles with two-way back-and-forth conversation (e.g., gives one-word answers, or lectures/monologues at length about their own favorite topic without noticing if the listener is bored) Takes language very literally; struggles to understand sarcasm, teasing, figures of speech, or "unwritten" social rules Unusual speech tone, rhythm, or volume (e.g., flat/monotone, sing-song, overly formal "little professor" vocabulary, or speaking too loudly) Difficulty making or keeping friends their own age; prefers solo play, gravitates toward adults or much younger children, or controls play rigidly In early childhood: showed less pretend/imaginative play with peers, preferring to line up toys, categorize objects, or examine parts of toys

Routines, Repetitive Behaviors & Sensory Sensitivities

Extreme distress or meltdowns over unexpected changes in schedule, transitions, taking a different route, or things not going "as planned" Highly intense, narrow, or encyclopedic focus on specific topics (e.g., specific video game lore, stats, dinosaurs, trains, maps, anime) Repetitive physical movements or vocal phrases when excited, stressed, or bored (hand-flapping, rocking, pacing, toe-walking, repeating movie lines/phrases) Tactile Sensitivity: Bothered intensely by clothing tags, sock seams, tight waistbands, water on face, hair brushing, or nail clipping Sound / Light Sensitivity: Covers ears or becomes overwhelmed in noisy cafeterias, assemblies, automatic toilets/hand dryers, vacuums, or bright lights Sensory Food Aversion: Extremely selective eating based on texture, smell, color, or specific brand; gags or refuses mixed foods Sensory Seeking / High Pain Tolerance: Constantly touches/smells objects, crashes into couches/people, craves heavy blankets, or seems unusually indifferent to pain or cold weather

Timing for Social Communication & Sensory Symptoms:

Past Only Current Only Both Past & Current None / N/A

4. Neurodevelopmental: Tics, Motor Coordination & Learning

Motor Tics: Sudden, involuntary, repetitive movements such as hard eye-blinking, nose twitching, facial grimacing, head jerking, or shoulder shrugging Vocal Tics: Repetitive throat-clearing, sniffing (when not sick), grunting, squeaking, coughing, or repeating syllables/words Reading / Dyslexia Signs: Difficulty sounding out words, slow or choppy reading aloud, poor spelling, or difficulty understanding what was just read Writing / Dysgraphia Signs: Awkward pencil grip, messy/slow handwriting, hand fatigue, or bright verbal ideas that they cannot get down on paper Math / Dyscalculia Signs: Trouble understanding number quantities, memorizing basic math facts, telling time on an analog clock, or solving word problems Motor Coordination: Appears clumsy or uncoordinated; struggled to learn to tie shoes, use buttons/zippers, ride a bike, or catch a ball Currently has (or has been evaluated for) a 504 Plan, IEP (Individualized Education Program), reading/math intervention, or classroom accommodations

Timing for Tics, Motor & Learning Symptoms:

Past Only Current Only Both Past & Current None / N/A

5. Physical & Somatic Signs of Childhood Distress

Children and teens frequently experience emotional stress, anxiety, or overwhelm through physical symptoms in their body.

Frequent Stomachaches or Nausea: Complains of tummy aches, cramping, or feeling like they might throw up—especially on school mornings, Sunday evenings, or before social/performance events Frequent Headaches: Complains of headaches or head pressure, particularly during or after school or stressful days Frequently visits the school nurse, asks to leave the classroom to use the restroom when stressed, or calls/texts parents begging to be picked up from school Sudden physical rushes of fear or panic (racing heart, feeling short of breath, dizziness, trembling, sweaty palms, or feeling faint) Daytime wetting, nighttime bedwetting (enuresis), chronic stool withholding, or bowel accidents (encopresis) after the age of expected toilet training Body-focused repetitive habits when anxious or bored (picking skin/scabs, biting nails or cuticles until sore, or pulling out hair/eyelashes/eyebrows)

Timing for Physical & Somatic Symptoms:

Past Only Current Only Both Past & Current None / N/A

6. Anxiety, Phobias, Perfectionism & Obsessive-Compulsive Symptoms

Separation Worry: Intense distress when separated from parents, difficulty with school drop-off, worries something bad will happen to family members, or refuses to sleep alone/attend sleepovers School Avoidance / Refusal: Extreme distress, crying, clinging, or refusal to get on the bus, exit the car, or enter the school building Social Anxiety: Intense fear of being judged, embarrassed, or called on in class; avoids speaking to unfamiliar adults, ordering at restaurants, or joining group activities Selective Mutism Pattern: Speaks freely and comfortably at home with close family, but becomes completely silent or frozen in school or around others Excessive "What-If" Worrying: Worries excessively about future events, grades, family finances, natural disasters/weather, germs/illness, or making mistakes Perfectionism: Gets deeply upset over minor mistakes, erases repeatedly or tears up homework if it isn't "perfect," or refuses to try new activities unless certain they will succeed Reassurance Seeking: Repeatedly asks the same questions over and over ("Are you sure?", "Will I be okay?", "Are you mad at me?") even after being reassured OCD-Type Rituals or Intrusive Thoughts: Repetitive handwashing, checking locks/items, counting, touching things symmetrically ("evening up"), bedtime rituals that must be done in an exact order, or confessing unwanted "bad thoughts"

Timing for Anxiety & OCD Symptoms:

Past Only Current Only Both Past & Current None / N/A

7. Mood, Irritability & Emotional Regulation

Note: In children and adolescents, depression often looks like chronic irritability, snappiness, or boredom rather than just crying.

Appears persistently sad, tearful, down, empty, or hopeless Chronic Irritability: Easily annoyed, grumpy, defensive, or snappy most of the day; family or teachers feel like they are "walking on eggshells" Explosive Meltdowns: Severe verbal or physical temper outbursts (screaming, slamming doors, throwing items) that are way out of proportion to the situation and take a long time to recover from Lost interest or pleasure in activities, sports, or friends they used to enjoy; isolates in their bedroom or says "everything is boring" Low self-esteem, excessive guilt, or harsh negative self-statements ("I'm stupid," "I ruin everything," "Nobody likes me") Rejection Sensitivity: Crushed, tearful, or enraged by mild feedback, gentle correction from a teacher/parent, or feeling left out by peers Noticeable drop in energy, slumping at desk, moving slowly, or a sudden drop in school grades and motivation Episodic Highs (Mania/Hypomania Screen): Distinct periods lasting several days in a row where the child had an uncharacteristically euphoric/giddy mood, acted invincible, talked non-stop, and slept only 3–4 hours yet woke up bursting with energy

Timing for Mood & Emotional Regulation Symptoms:

Past Only Current Only Both Past & Current None / N/A

8. Behavioral, Oppositional & Screen/Digital Regulation

Frequently argues with adults, debates or negotiates every request, or actively refuses to comply with household or classroom rules Often deliberately annoys siblings or classmates, or reflexively blames others for their own mistakes or misbehavior Screen / Gaming Dysregulation: Intense anger, refusal, or meltdowns when asked to turn off video games, tablets, phones, or TV Physical aggression when angry (hitting, kicking, pushing, biting) or breaking/destroying toys, electronics, or household property Frequent lying to get out of trouble, sneaking food/items, taking things that don't belong to them, skipping classes, or running/bolting away Suspected or known experimentation with vaping/nicotine, cannabis/THC, alcohol, energy drink overuse, or other substances

Timing for Behavioral & Oppositional Symptoms:

Past Only Current Only Both Past & Current None / N/A

9. Sleep, Appetite, Trauma, Bullying & Safety

Sleep Onset / Bedtime Struggles: Takes over an hour to fall asleep, cannot shut off their brain at night, or requires a parent in the room to fall asleep Overnight Sleep Disturbances: Frequent nightmares, night terrors, sleepwalking/talking, loud snoring/mouth-breathing, teeth grinding, or restless legs Eating / Body Image Concerns: Poor appetite or poor weight gain, binge/secret eating, skipping meals, or preoccupation with weight/body shape Bullying / Peer Stress: Has experienced bullying, teasing, social exclusion, or stressful online/social media interactions Stressful or Traumatic Events: Has experienced a major stressor, loss, family separation, frightening medical procedure, accident, or trauma (with ongoing nightmares, jumpiness, or avoidance) Perceptual Concerns: Has mentioned hearing voices or whispers when alone, seeing shadows/figures, or expressing extreme paranoia/suspiciousness Self-Harm / Self-Injury: Has hit themselves, banged their head, scratched, cut, or otherwise intentionally hurt their body when upset Suicidal Statements / Thoughts: Has talked about wishing they weren't born, wanting to disappear/go to sleep forever, or thoughts of hurting/killing themselves

Timing for Sleep, Trauma & Safety Concerns:

Past Only Current Only Both Past & Current None / N/A

10. Setting Comparison & Additional Observations

Do these behaviors look different at school/public compared to at home? (e.g., "Holds it together all day at school and then melts down the moment they get home")

Any additional context, triggers, academic feedback, or observations you would like Dr. Amin to know? (Do NOT include names)

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