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1 Clackamas Pediatric Clinic Oregon Pediatrics Meridian Park 8645 SE Sunnybrook Blvd # SW 65 th Ave #275 Clackamas, OR Tualatin, OR (503) (503) Oregon Pediatrics Happy Valley Oregon Pediatrics NE Portland SE Misty Dr. # NE Hoyt St. #B55 Happy Valley, OR Portland, OR (503) (503) Central Fax (503) Patient Accounts (503) PATIENT INFORMATION Patient Name: DOB: Other Names Used: Preferred Pronoun: Preferred Language: Ethnicity: Referred by (Name & Number): BIOLOGICAL PARENTS & CONTACT INFORMATION Mother s Name: Marital Status: DOB: Phone: May we leave a detailed message: Y N Father s Name: Marital Status: DOB: Phone: May we leave a detailed message: Y N PRIMARY CAREGIVER & CONTACT INFORMATION (Complete only if Biological Parent is not the Primary Caregiver) Guardian s Name: Marital Status: DOB: Relationship to Child: (e.g., Adoptive, Guardian, Foster, Step, Other) Phone: May we leave a detailed message: Y N Guardian s Name: Marital Status: DOB: Relationship to Child: (e.g., Adoptive, Guardian, Foster, Step, Other) Phone: May we leave a detailed message: Y N Please note patient s current household: CURRENT LIVING SITUATION Name Age Relationship to patient
2 Please note any custody arrangements, if applicable: Any history with CPS (nature of allegations, age of occurrence, offender, dependency court action, child/parent response, placement and type, services): Yes No If yes, please describe: Is there any other information regarding patient s past/current living situation(s) we should be aware about or that you feel impact patient s current functioning? FAMILY HISTORY Have there been any major changes in your family in the past few years (e.g. moved, employment changes, deaths, family dynamic): Briefly describe patient s relationship with mother: Briefly describe patient s relationship with father: Briefly describe patient s relationship with siblings: Briefly describe patient s relationship with any other significant person(s): Is there any history of mental illness in the patient s family? If yes, please describe: Is there any history of substance use in the patient s family? If yes, please describe: 2 P a g e
3 REASON FOR REFERRAL/CHIEF COMPLAINT Describe the problem(s) that brought you here today (please include how long symptoms/concerns have been present in the chart provided below): CURRENT SYMPTOMS AND BEHAVIORS Symptoms and/or Behavioral Concerns When did they start How often are they experienced Problems created from these concerns Please check all behaviors and symptoms that you consider problematic: Acts younger than age Aggression/fights Alcohol/drug use Anxiety/worry Boredom Change in appetite Compulsive behavior Computer addiction Crying spells Curfew violations Cutting Defiance Delusions Destroys property Difficulty keeping friends Difficulty making friends Distractibility Eating problems Elevated mood Family conflict Fatigue Fear away from home Fire setting Frequent arguments Gambling Grandiosity Grief Guilt Hair pulling Hearing voices Homicidal thoughts Hopelessness Hyperactivity Impaired Judgment Impulsivity Irritability/Anger Lack of motivation Learning Disability Legal problems Loneliness Loss of pleasure in activities Low self-worth Lying Manipulative behavior Nightmares No/few friends Obsessive thoughts Oppositional Behavior Other (specify): Panic attacks Peer conflict Peer/sibling conflict Phobias Picking behaviors Poor memory/confusion Racing thoughts Recurring, disturbing memories 3 P a g e
4 Running away Sadness/Depression Self-harm behaviors Sexual behavior Sleep problems Social discomfort Somatic Complaints Stealing Suicidal thoughts Suicide Attempts Suspicion/paranoia Swearing Thoughts of death Toileting problems Visual hallucinations Wide mood swings Withdrawal from people Work/school problems SUICIDAL THOUGHTS/ATTEMPTS: Self-Harm (without statement of suicidal intent This may include thoughts and/or actions): Yes No Unable to Assess If yes, describe (include behavior, when started, most recent time): Suicidal attempts: Yes No Unable to Assess If yes, describe (include behavior, when started, most recent time): Psychiatric Hospitalization: Yes No Date(s): MENTAL HEALTH HISTORY Prior Mental Health Records to be requested from: Yes No Type of Treatment When (Month/year) Name of Provider/Program Outpatient Counseling (Self-help/Support Groups/ In School) Drug/Alcohol Treatment Concerns for drug and/or alcohol use: Yes No If yes, explain: 4 P a g e
5 TRAUMA If not applicable, please leave blank and continue to next question Does patient have any trauma or exposure to trauma: Yes No Unable to Assess Trauma type (physical, emotional/verbal, sexual, witness to abuse, violence or threats of violence) Dates Received Therapy for this? (Yes or No) Response at end of therapy MEDICATIONS If not applicable, please leave blank and continue to next question If patient is not a current Clackamas and Oregon Pediatric patient, please list "all" past and present psychotropic medications used, prescribed/non-prescribed Medication Dosage/Frequency Reason/Diagnosis Period Taken Effectiveness/Response Side Effects/Reactions PATIENT STRENGTHS (to assist in achieving treatment goals): athletics, clubs, affiliations, social, personal, relations, etc. SOCIAL/CULTURAL/SPIRITUAL Describe any church, religious or spiritual group or community that your family is currently involved in: 5 P a g e
6 Have you found spiritual beliefs to be helpful or a hindrance to your family? How important are spiritual matters to your family? Not at all A little Fairly important Very important SCHOOL HISTORY School: Grade Level: Receiving Special Education: Yes No On IEP: Yes No Current IEP Dates: Eligibility category: On 504 Accommodation Plan: Yes No Type of Accommodations: Has the patient had any of the following at school? Associates with older children Gang influence Associates with younger children Incomplete homework Attendance problems Learning problems (math, reading, writing) Been accused of bullying Poor grades Referrals or detentions Speech problems Teased or picked on Suspension - reason: Educational Comments: Performance, Grades, School Changes, any other concerns: LEGAL HISTORY Juvenile Court History (arrests/offenses, tickets/warnings, probation/stipulations, incarceration, placement: Is there anything else you feel it is important for Behavioral Health to know before beginning? 6 P a g e
x S. Broadway, Suite 7 Pitman, NJ Intake Form
Intake Form Name: Date: *If attending couples or family therapy please complete one form for each individual attending treatment. Presenting Problems and Concerns Describe the Problem that brought you
Child/ Adolescent Questionnaire
Oconee Center for Behavioral Health 1360 Caduceus Way Building 400, Suite 102 Tel 706-286-8442 Fax 706-310-6907 Child/ Adolescent Questionnaire Patient s Name: Date of Birth: / / Patient s Birthplace:
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
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
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.
*Please complete this form and bring to your first appointment. This information is fundamental to the assessment and treatment process. PATIENT CONTACT INFORMATION Name Age Date of birth Phone ( ) Mailing
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
Adult Intake Form. Name: Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem:
Adult Intake Form Date: Describe the problem that brought you here today: Briefly share relevant history behind this problem: Check any of the following symptoms that you are experiencing: Distractibility
Adult Information Form Page 1
Adult Information Form Page 1 Client Name: Age: DOB: Date: Address: City: State: Zip: Home Phone: ( ) OK to leave message? Yes No Work Phone: ( ) OK to leave message? Yes No Current Employer (or school
Adult Information Form
1 Client Name: Age: DOB: Today s Date Address: City: State: Zip: Home Phone: ( ) Ok to leave message? YES NO Work Phone: ( ) Ok to leave message? YES NO Current Employer (or school if a student): Gender:
507 N Davis Drive Suite 1A Warner Robins, GA Phone: (478) Fax: (478)
Office Use Only Client # Ins. Dx: Need Monthly Statement? Yes No EAP Yes No Individual Family Today s Date: GENERAL INFORMATION Please print Client Name: Last First: MI: Mailing Address: City: State: Zip:
Patient Questionnaire. Name: Date: A. What are the main concerns or problems that brought you here today?
Patient Questionnaire Name: Date: D.O.B.: Age: Referred By: Presenting Problem A. What are the main concerns or problems that brought you here today? B. Problem Checklist: please circle all that apply:
Full Circle Psychotherapy: Ayla Marie Carter, MA, LMHC
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Child and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
COUNSELING ASSESSMENT REFERRAL AND BACKGROUND INFORMATION (Adult Form) cell telephones/fax #s/ addresses: (Spouse): (Emergency Contact):
Joanna C. Ioannides, LCSW *Lowry Counseling, LLC *7581 E. Academy Blvd. Ste 209 * Denver, CO 80230*Ph. (720)319-7319 Fax (303)379-4607* counseldenver@aol.com* COUNSELING ASSESSMENT REFERRAL AND BACKGROUND
2550 Middle Road, Suite 316 Bettendorf, Iowa Adult Intake Form
Adult Intake Form 2550 Middle Road, Suite 316 Bettendorf, Iowa 52722 563.265.1529 annika@qcwomenstherapy.com Thank you for choosing Quad City Women s Therapy. I collect the following information help me
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone:
Client s Name: Today s Date: Partner s Name (if being seen as a couple): Address, City, State, Zip: Home phone: Work phone: Cell phone: Private email address: Student? If yes, where and major? May we leave
Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -.
New Client Intake Date: Client Name: Date of Birth: Address: City: Zip code: Hm #: ( ) -. Cell#: ( ) -. Wrk#: ( ) -. Otr#: ( ) -. Employer Email: Emergency Contact Name Relationship Phone number TREATMENT
Client Intake Form. First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip:
Client Intake Form First Name: M.I.: Last Name: Birthdate: Gender: Age: Address: City: State: Zip: Tel: Home: Okay to leave message? (Circle one) Yes No Tel: Work: Ext Okay to leave message? (Circle one)
Psychiatric Residential Treatment Facility Referral
Psychiatric Residential Treatment Facility Referral Psychiatric residential treatment facility (PRTF) referral information Date of referral: Referral contact: Phone number: Referring facility or agency:
Address: Spouse/Partner Name: Phone: Address:
Adult Wellness Assessment Please take a few minutes to fill out this form. The information will be helpful in better understanding your individual needs and situation. Thank you. Personal Information Name:
Biographical History Form Child/Adolescent
Biographical History Form Child/Adolescent First Name: Middle Name: Last Name: Address: Child s Age: Child s DOB: / / Male Female Today s Date: / / Mother/Guardian: Cell #: Home#: Father/Guardian: Cell
JILL L. KOFENDER, PHD, PLLC. Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE. Client s Name Today s Date Gender Age Birthdate
JILL L. KOFENDER, PHD, PLLC Licensed Clinical Psychologist ADULT CLIENT QUESTIONNAIRE Client s Name Today s Date Gender Age Birthdate Cell Phone Is it ok to text? Y N Is it ok to receive appt. reminders?
Client Intake Form. Briefly describe the reason(s) you are seeking psychotherapy at this time:
Client Intake Form Thank you for taking the time to openly and honestly answer the questions below. Your genuine responses are appreciated, as all information provided will assist your therapist to better
ADULT INTAKE QUESTIONNAIRE. Ok to leave message? Yes No. Present psychological difficulties please check any that apply to you at this time.
ADULT INTAKE QUESTIONNAIRE Name: Today s Date: Age: Date of Birth: Address: Home phone: Work phone: Cell phone: Ok to leave message? Yes No Ok to leave message? Yes No Ok to leave message? Yes No Email:
CLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
MINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
Name: Birthdate: Gender: Address: Phone: (Home) (Work) (Cell) Highest Education Attended: Occupation: Place of Employment:
CLIENT CLIENT INTAKE FORM Client Information Name: Birthdate: Gender: Address: Is it safe to send correspondence to this address, if needed? Yes No Phone: (Home) (Work) (Cell) Is it safe to contact/leave
MINDFUL WELLNESS CENTER, PLLC
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CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake)
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Associates of Behavioral Health Northwest CHILD/ADOLESCENT PSYCHOSOCIAL ASSESSMENT
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Health and Social Information 1. How is your physical health at present? (Please circle) Poor Unsatisfactory Satisfactory Good Very good
Client Health History and Background Please provide the following information for my records. Continue on the backside of this form if you need additional space. General Information Name: Date: Birth Date:
Restore Counseling Center 630 E Southlake Blvd, Ste 127, Southlake, Tx
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COUNSELING INTAKE FORM
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CLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
ADULT INTAKE FORM. Name
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Client Information Form
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CONFIDENTIAL. Name Today s Date. Address: City: State: Zip: Phone number (cell): (home): (work): address: Emergency Contact (name): (number):
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Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
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Hawthorne Veteran and Family Resource Center. Recuperative Care Program Referral Form. 250 N. Ash Street. Escondido, CA 92027
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