Child/ Adolescent Questionnaire
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1 Oconee Center for Behavioral Health 1360 Caduceus Way Building 400, Suite 102 Tel Fax Child/ Adolescent Questionnaire Patient s Name: Date of Birth: / / Patient s Birthplace: Sex: M F Person completing this form: Relation to Child: Who Referred you to our Practice? _ Please check all of the behaviors and symptoms that you consider problematic: Distractibility Change in appetite Visual Hallucinations Manipulative behavior Hyperactivity Withdrawal from people Defiance No/few friends Impulsivity Anxiety/worry Aggression/fights Eating problems Boredom Panic attacks Homicidal thoughts Sleep problems Fear away from home Frequent Arguments Nightmares Sadness/depression Social discomfort Irritability/anger Toileting Problems Hopelessness Phobias Peer/sibling conflict Fire Setting Thoughts of Death Obsessive Thoughts Stealing Work/School Problems Self-harm behaviors Compulsive behavior Destroys property Legal Problems Crying Spells Racing thoughts Running away Sexual Behavior Loneliness Wide mood swings Swearing Computer addiction Low self-worth Suspicion/ paranoia Curfew Violations Alcohol/drug use Fatigue Hearing Voices Lying Lack of motivation Poor memory/ confusion Recurring, disturbing memories Other: Please Briefly describe the problems for which you are seeking help at this time: Approximate date of onset of problems:
2 Has the patient ever received outpatient mental health treatment? No Yes If yes, please list in order, including Psychological, School, or IQ testing: Clinician/ Doctor Approximate Date of Evaluation/Treatment Type of Evaluation How Often did you visit said Clinician/Doctor Has the patient ever received inpatient mental health treatment? No If yes, please list in order: Yes Hospital Name Dates of Treatment Reason for hospitalization Has the patient ever threatened or attempted suicide? No Yes Family Psychiatric History: Please note any history of ADHD, Learning Disorders, Depression, Bipolar Disorder, Anxiety Disorders, Obsessive-Compulsive Disorder, Tic/ Tourette s, Schizophrenia, Drug or Alcohol Abuse, Suicide attempts, or other Psychiatric Problems in your grandparents, parents, siblings, or 1 st cousins. Affected Family Member Type of Mental Illness or SA Treatment (If Any)
3 Please tell us a little about the Patient s childhood development: Please answer the following as best as you can recall: Pregnancy- Please check and describe any that apply to the mother s pregnancy with the patient: Received prenatal care Drank alcohol during pregnancy Smoked during pregnancy Used drugs during pregnancy Took Medications Infection(s) Nausea or vomiting Severe Emotional Distress Elevated blood pressure Diabetes of pregnancy Pre-eclampsia Premature labor Threatened miscarriage Motor Development sitting, crawling, walking, etc. Normal Fast Slow Speech and Language Normal Fast Slow Self-Help Skills- dressing, brushing, toileting, hygiene, etc. Normal Fast Slow Please tell us a little about the patient s social history: Current City of Residence: Currently Living with: Both Bio parents Bio Father Bio Mother Other: Please Explain Other: Other Children in Family: No Yes If yes, please list: Child Age Is the patient adopted? No Yes If yes, please explain the circumstances of the adoption:
4 Has the patient ever experienced or witnessed any physical abuse, sexual abuse, or neglect? No Yes If yes, please describe: Please tell us a little about the patient s school history: School: Grade: Current Academic Performance: Good Fair Poor N/A Past Academic Performance: Good Fair Poor Past Behavioral Performance: Good Fair Poor Grades Repeated: Has the patient ever been in any special education programs? No Yes Any known learning disabilities? No Yes If yes, please explain: Legal Problems: Has the patient ever been arrested or had any legal charges files against them? No Yes Substance Use: Do you suspect that the patient has ever used tobacco, alcohol, or drugs? No Yes
5 Please tell us a little about the patient s medical history: Who is the patient s Primary Care Doctor? When was his/her last physical examination? Does the patient have any current Medical Problems? No Yes If applicable, please list any PAST psychiatric medications: If we have not provided enough space please feel free to use the bottom or back of this page. Medicine #1 Medicine #2 Medicine #3 Medicine #4 Medicine #5 Medicine Strength How many pills do you take at a time? How many times of day do you take this medicine? What does this medicine treat? prescribing doctor? Please list any CURRENT Medications on the last page.
6 If applicable, please list any CURRENT medications: If we have not provided enough space please feel free to use the bottom or back of this page. Medicine #1 Medicine #2 Medicine #3 Medicine #4 Medicine #5 Medicine Strength How many pills do you take at a time? How many times of day do you take this medicine? What does this medicine treat? prescribing doctor? Patient Signature Date Relationship to patient
Name Age Relationship to patient
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Demographic Information Form
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
CLIENT INFORMATION FORM. Name: Date: Address: Gender: City: State: Zip: Date of Birth: Social Security Number:
Name: Address: Gender: City: State: Zip: Date of Birth: Social Security Number: Contact Telephone Numbers Please complete relevant information and indicate the number at which you wish to be contacted
Please check all the behaviors and symptoms that you consider problematic:
Name Date Address Phone # Date of birth Email address Social Security Describe the issue that brought you here today: Please check all the behaviors and symptoms that you consider problematic: Distractibility
Intake Form. Presenting Problems and Concerns. When did it start and how does it affect you:
Intake Form Name: Date: Presenting Problems and Concerns Describe the problem that brought you here today: When did it start and how does it affect you: Estimate the severity of the above problem: Mild
Demographic Information Form
Demographic Information Form PATIENT INFORMATION Male Female Other / / (Patient Legal Last Name) (Patient Legal First Name) (MI) (DOB) Mailing: SSN#: - - Home Cell Relationship Status (circle one): Single
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process.
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Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
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Deborah L. Galindo, Psy.D. 2601 25 th St. SE, Ste 420 Salem, OR 97302 Phone: 503-364-6093 Fax: (503) 566-9864 or (503) 364-5121 COUPLES THERAPY INTAKE QUESTIONNAIRE (EACH PARTNER NEEDS TO COMPLETE THIS
Evergreen Behavioral Health Psychiatric Intake Form. Name: Date: Date of Birth:!
Name: Date: Date of Birth: NOTE: Please also fill out the standard Evergreen Behavioral Health Adult Client Information form to accompany this one if you have not yet done so. Please also bring in recent
PHARMACY INFORMATION:
Patient Name: Date of Birth: Referred by: Reason for Visit: Current psychiatric medications and doses: PHARMACY INFORMATION: Name of Pharmacy: Phone Number: Fax Number: Address: PRIMARY CARE PHYSICIAN
SHODAIR ADMISSION ASSESSMENT FORM. Pa tie nt Living Arrangement: Pa re nts Group Home Foste r Home JDC She lte r Othe r:
SHODAIR ADMISSION ASSESSMENT FORM Date: Referring Party: Phone#: Pa tie nt Living Arrangement: Pa re nts Group Home Foste r Home JDC She lte r Othe r: Patient Name: Patient DOB: Age: Male Female Patient
Susan Weltner-Brunton, Ph.D. & Associates, Inc. 921 Chatham Lane, Suite 112 Columbus, Ohio Phone Fax
Susan Weltner-Brunton, Ph.D. & Associates, Inc. 921 Chatham Lane, Suite 112 Columbus, Ohio 43221 Phone 614-754-7648 Fax 614-754-7965 An Association of Independent Practitioners Susan Weltner-Brunton, Ph.D.
Mental Illness and Disorders Notes
Mental Illness and Disorders Notes Stigma - is a negative and often unfair about mental illness and disorders can cause people with these to not seek help. Deny problem, feel shame and -feel as if they
C O U P L E S I N T A K E F O R M
COUPLE S INTAKE FORM CONFIDENTIAL Name Today s Date Contact information: Address: City: State: Zip: Phone number (cell): (home): (work): Email address: Date of Birth May I leave a voicemail on your cell
Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA Phone:
1 Driftwood Psychological Services 664 Scranton Rd., Suite 201 Brunswick, GA 31525 Phone: 912-230-2436 drtara@driftwoodpsych.com Client name Date ADULT HISTORY FORM Presenting problems Why I came for counseling: