Initial Evaluation (Play Therapy)

Client Name: [Child's full name]

Date of Birth: [Date of birth]

Date of Service: [Date of service]

Clinician: [Clinician name, credentials]

Participants Present: [Participants and portions attended] (List who attended and for which portions: parent-only interview, child-only play session, joint feedback.)

Administrative & Consent

• [Referral source and reason] (Identify who referred and the stated reason; include date of referral if available.)
• [Legal guardian(s) and custody status] (Specify legal custody; note if court-ordered or restricted. Indicate documentation reviewed vs. caregiver report.)
• [Informed consent from guardian] [obtained / not obtained] (If not obtained, state reason and plan to obtain.)
• [Child assent] [obtained / not obtained / not developmentally appropriate] (Briefly note approach used if obtained.)
• [Confidentiality limits] (Document that limits were explained to child and caregivers in developmentally appropriate language.)
• [Releases of information] (List obtained or requested ROIs with targets such as school, pediatrician, prior providers; include status and plan for pending items.)
• [Incomplete administrative elements] (Note reason for any missing documents/information and follow-up plan. Omit if all elements complete.)

Presenting Concerns

Chief concern (caregiver's words): "[Caregiver-stated concern]"

[Narrative history of concerns] (Synthesize onset, duration, and course; frequency, intensity, and triggers; impairment across settings [home, school, peers]; prior strategies or interventions tried and response; and the child's perspective including brief quotes when salient. Clearly label the informant for each piece of information. If information is incomplete, state what was gathered and what will be completed next.)

Current functioning snapshot: [Sleep patterns; appetite; mood variability; separation tolerance; behavioral regulation] (Use age-appropriate descriptors; label informant for each domain.)

Developmental History

• [Prenatal/perinatal history] (Include only if relevant; note source. Mark high-value unknowns as "not obtained.")
• [Early temperament and attachment patterns] (Brief descriptors; note source.)
• [Developmental milestones] (Motor, speech/language, social communication, toileting; include ages achieved or concerns; note source.)
• [Sensory processing patterns] (Seeking/avoidance, sensitivities; note source.)
• [Sleep history] (Onset/maintenance, routines, co-sleeping, nightmares; note source.)
• [Play development] (Pretend/symbolic play, flexibility, joint attention, narrative capacity; note source.)
• [Strengths and interests] (Preferred activities, talents, motivators; note source.)

Medical History

• [Primary care provider and last well visit] (Include clinic name/date if known; indicate if per caregiver report.)
• [Active medical conditions] (Brief list with relevance to behavioral health.)
• [Current medications] (Psychiatric and non-psychiatric; doses/frequency if provided.)
• [Allergies/adverse reactions] (Medication and non-medication.)
• [Vision/hearing concerns] (Screening results if available.)
• [Head injuries, seizures, hospitalizations, surgeries] (Summarize with approximate dates.)
• [Prior developmental evaluations] (OT, speech, neuropsych; summarize key findings and indicate records reviewed vs. per report.)

Behavioral Health History

• [Prior therapy/behavioral services] (Type, duration, modality, perceived benefit, reasons for ending; present chronologically. Distinguish caregiver report vs. records.)
• [Prior diagnoses] (List with context and any diagnostic uncertainty.)
• [Psychiatric medication trials] (Medication, dose range, response, adverse effects; dates if known.)
• [Higher levels of care] (ED visits, hospitalizations, intensive programs; dates and reasons.)
• [Past risk behaviors] (Self-harm, aggression, elopement, other; include approximate timing and severity.)

Trauma & Adverse Experiences

• [Adverse experiences summary] (Brief, minimum necessary detail; e.g., separations, losses, conflict, bullying, medical trauma, placement changes, migration-related stress.)
• [Approximate timing and duration] (Developmental stage when events occurred.)
• [Current safety status] (Document current safety and any ongoing risk.)
• [Current clinical impact] (Link to symptoms, regulation, relationships, or functioning.)
• [Abuse/neglect concerns and mandated reporting] (State whether concerns were disclosed or suspected and if a report was made; detailed actions go in Risk Assessment.)

(If trauma history was not fully assessed, explicitly state that it is incomplete and outline plan to complete.)

Family & Home Environment

• [Household composition] (Who lives with the child; siblings; significant caregivers.)
• [Parenting routines and transitions] (Daily structure, transitions between households if applicable.)
• [Discipline approaches and caregiver alignment] (Consistency, strategies, areas of mismatch.)
• [Current family stressors] (Housing, caregiver health, work schedules, financial or legal stressors.)
• [Family psychiatric/substance use history] (First-degree relatives emphasized.)
• [Protective factors] (Supportive relationships, routines, community or cultural resources.)

School Functioning

• [School name, grade, teacher/classroom context] (Class size, general/special education setting.)
• [Attendance patterns] (Tardies, absences, refusal; recent changes.)
• [Academic strengths and struggles] (Specific subjects, learning concerns.)
• [Behavioral functioning in class] (Disruptions, shutdowns, peer conflict, regulation.)
• [Current supports] (IEP/504, counseling, behavior plans, OT/speech; services received and frequency.)
• [Disciplinary history] (Office referrals, suspensions, expulsions; brief context. Omit if none.)
• [Plan for school collateral] (Teacher rating scales, IEP review, staff contacts; specify what is requested/pending.)

Social & Cultural Context

• [Peer relationships] (Friendships, conflicts, social approach/avoidance, bullying experiences.)
• [Activities and interests] (Clubs, sports, hobbies, community engagement.)
• [Digital media patterns] (Include only if clinically relevant.)
• [Cultural and linguistic factors] (Languages at home, migration history, identity factors, beliefs affecting care access or symptom expression.)

Measures & Collateral

• [Standardized measures administered] (Name, informant, date, scores, and brief clinical interpretation.)
• [Records reviewed] (Prior evaluations, IEPs, pediatric notes; list with key takeaways.)
• [Collateral contacts completed] (Name, role, method, date, and salient points.)
• [Pending collateral] (What is outstanding and how results will be integrated.)

Play Therapy Observations

Session structure: [Time allocation across parent-only, child-only, and joint portions; child's separation tolerance]

Engagement and regulation: [Entry to playroom, warming up, flexibility, frustration tolerance, co-regulation needs, sensory seeking/avoidance] (Use neutral behavioral descriptors.)

Play characteristics: [Types of play observed: pretend/symbolic, exploratory, rule-bound, repetitive; narrative coherence; rigidity vs. flexibility] (Describe patterns without interpretation.)

Observed themes: [Patterns noted in play such as mastery/control, fear/safety, nurturing/caregiving, aggression/protection, rescue, rejection] (Document as observed patterns rather than conclusions.)

Relational style: [Directedness, bids for connection, eye contact, boundary testing, response to limits]

Affect: [Range, congruence with play content, shifts, recovery time]

Clinician interventions: [Limits set, safety redirections, supportive strategies used] (Avoid detailed process content.)

Functional synthesis: [2–4 sentence synthesis linking observed play to regulation capacity, relational functioning, and treatment implications] (Label interpretive statements as hypotheses.)

Mental Status Examination

• Appearance: [Appearance and grooming]
• Behavior and psychomotor: [Activity level, separation response, engagement with clinician, eye contact, cooperation]
• Speech and language: [Rate, volume, articulation, reciprocity; language level relative to developmental expectations]
• Mood (reported): [Child/caregiver-reported mood] (Quote brief descriptors if offered.)
• Affect (observed): [Range, intensity, stability, congruence]
• Thought process: [Logical/goal-directed vs. tangential, loose, perseverative]
• Thought content: [Worries, fears, guilt; suicidal or homicidal ideation as developmentally appropriate] (Document presence or absence.)
• Perception: [Hallucinations or illusions] (If assessed; note denial if appropriate.)
• Cognition: [Attention, orientation, memory, fund of knowledge] (Use observational proxies if formal testing not performed; anchor to developmental expectations.)
• Insight and judgment: [Developmentally anchored assessment]
• Impulse control: [Within-session observations]

(If any domain could not be fully assessed due to age, language, or dysregulation, state why and note observational proxies used.)

Risk Assessment

Suicide/Self-Harm: [Ideation (passive/active), plan, intent, means access, preparatory behaviors, past attempts, non-suicidal self-injury] (Document presence or absence for each element.)

Harm to Others: [Threats, intent, access to weapons, past aggression or assaults]

Other Safety Concerns: [Elopement, fire setting, cruelty to animals, severe impulsivity, sexual behavior concerns, severe property destruction] (Include only if relevant.)

Mandated Reporting: [Abuse/neglect concerns, whether a report was made, to whom, and immediate safety steps taken]

Protective Factors: [Supportive relationships, reasons for living, school/community connection, treatment engagement]

Overall Risk Level: [Low / Moderate / High] (Provide brief clinical rationale.)

Mitigation Plan: [Safety plan elements, caregiver supervision plan, crisis contacts provided, lethal means counseling if relevant, escalation pathway] (If risk assessment could not be completed, document the reason, immediate safeguards, and urgent follow-up.)

Diagnostic Impression

• Primary diagnosis: [Diagnosis or working/provisional diagnosis with specifiers] (Use uncertainty language when data is insufficient.)
• Secondary diagnoses: [Comorbidities if applicable]
• Differential diagnoses: [Brief supporting and non-supporting findings]
• Rule out: [Neurodevelopmental, sleep, learning, or medical contributors; include plan to clarify]

Clinical Formulation

[Biopsychosocial integration] (1–2 concise paragraphs summarizing predisposing factors [temperament, neurodevelopmental vulnerabilities, family history, early adversity], precipitating factors [recent transitions, losses, acute stressors], perpetuating factors [avoidance cycles, reinforcement patterns, sleep disruption, family/school responses], and protective factors [strengths, supportive adults, interests, engagement]. Distinguish observations from inferences.)

Play-based hypothesis: [Hypothesis linking observed play/regulatory patterns to coping style, need for control, attachment patterns, or fear/safety themes] (Label clearly as hypothesis to be tested in treatment.)

Treatment Plan

Problems/Targets:

• [Problem/target 1] (Prioritize safety, then impairment.)
• [Problem/target 2]
• [Problem/target 3] (Add/remove as needed.)

Goals (measurable):

• [Goal 1 in observable terms: frequency/intensity/duration/setting]
• [Goal 2 in observable terms: frequency/intensity/duration/setting]
• [Goal 3 in observable terms: frequency/intensity/duration/setting] (2–5 total goals.)

Interventions:

• [Play therapy approach: child-centered / directive / trauma-informed / CBT-informed play] (Align to targets; note core strategies.)
• [Parent work] (Coaching, psychoeducation, caregiver session frequency, home practice.)
• [School collaboration plan] (Consent for contact, specific coordination steps.)

Frequency and Duration: [Session frequency; expected treatment duration or phase; parent session cadence]

Referrals and Coordination: [Psychological testing, neurodevelopmental evaluation, pediatric follow-up, psychiatry consultation; specify reason and urgency]

Safety Plan: [Reference Risk Assessment; restate key crisis contacts and escalation pathway]

Next Steps: [Follow-up appointment date or interval; tasks to complete such as school collateral, additional measures, continued history] (State who is responsible for each task.)