FAMILY HISTORY: John lives with his parents and younger sister in a suburban neighborhood. His father is a software engineer, and his mother is a teacher.
John is a curious and imaginative 8-year-old boy who loves reading and building with LEGO. He is friendly and enjoys making new friends.
John has had positive social experiences at school, though he sometimes struggles with sharing and taking turns. He has made significant progress in these areas over the past year.
MEDICAL AND DEVELOPMENTAL: John was born full-term with no complications. He met all his gross motor milestones on time and enjoys playing soccer.
His fine motor skills are well-developed, and he excels in drawing and writing.
John is bilingual, speaking both English and Spanish fluently. He had a slight delay in speech development but has since caught up.
He shows strong cognitive abilities, particularly in problem-solving and logical reasoning.
John's healthcare team includes a pediatrician and a speech therapist.
He is not currently on any medications.
John has a regular sleep schedule, though he occasionally has difficulty falling asleep.
He has a healthy appetite and no eating concerns.
John has mild asthma, which is well-managed, and no other significant medical conditions.
He is sensitive to loud noises, which can cause him to become anxious.
John is independent in most daily living skills, though he sometimes needs reminders to complete tasks.
There is a family history of asthma on his father's side.
MENTAL HEALTH: John has not been diagnosed with any mental health conditions.
He previously exhibited some anxiety-related behaviors, which have improved with support.
Cognitive-behavioral strategies have been effective in managing his anxiety.
John becomes dysregulated when overwhelmed by noise or changes in routine.
There are no concerns about self-harm or self-deprecating statements.
John has a positive relationship with his therapist, which has been beneficial.
He does not exhibit any significant ritualized or compulsive behaviors.
ACADEMIC: John is in the third grade at Maple Elementary School.
He receives support for his mild speech delay but does not have any special education designations.
Previous assessments indicate above-average cognitive abilities.
John occasionally struggles with reading comprehension but receives support from his teacher.
He is proficient in math and enjoys solving puzzles.
Teachers report that John is a diligent student but can become fixated on completing tasks perfectly.
