Minor Intake Form. Child s Name DOB
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- Elmer Wheeler
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1 Page 1 of 5 Minor Intake Form Child s NameDOB Current Concerns: What concern brings you or your child in? When did this concern begin? (Please attempt to use dates.) Has your family/child been in therapy before or received any prior professional assistance for your mental well-being? If so, please give dates: What do you hope to accomplish in counseling for your child? Please rate how much support you and your family have overall: A Lot Some Limited Very Little None Are there any cultural, religious, spiritual, or ethnic factors for your family that you would like me to be aware of? If yes, please describe: What does your child enjoy doing in his or her free time, either on his/her own or with others?
2 Page 2 of 5 What would you say are your child s strengths? School Issues Are you concerned about behavior at school? If so, explain. Are you concerned about your child s academic progress at school? Does your child enjoy school? Physical Health What activities does your child engage in to stay physically healthy? (i.e., exercise, sleep, diet, meditation, etc.): Do you have any current concerns about your child s physical health? Please specify: Does your child you have a physical/medical health provider? If yes, what is his or her name? Please list medicines your child is currently taking, or has taken during the past 6 months (include any medicines that were prescribed or taken over the counter): Medication: Dosage:_ Prescribed By: Medication: Dosage:_ Prescribed By: Medication: Dosage:_ Prescribed By:
3 Page 3 of 5 Physical Symptoms Check any of the following symptoms that apply to your child: Headaches Stomach issues Skin problems Dizziness Tics Dry mouth Palpitations Fatigue Burning /itchy skin Muscle spasms Twitches Chest pains Tension Back pain Rapid heart beat Sexual disturbances Tremors Unable to relax Fainting spells Blackouts Bowel disturbances Use Laxatives Excessive sweating Tingling Watery eyes Visual disturbances
4 Page 4 of 5 Numbness Flushes Hearing problems Don t like being touched Poor appetite Binge/Purge Constipation Allergies Nausea Substance Use Please share information about the substances that you know/believe your child has used within the past year. Include street drugs, misuse of prescription medication, and use of medication not prescribed. Substance- How much and how often? When last used? Age started using Please share information about substance use by other people living in the child s home. Mental Health History Has anyone in the immediate family ever been hospitalized for psychiatric reasons? If yes, please provide dates: Has anyone in the immediate family attempted suicide? If yes, when was the most recent attempt? Does your child do things that other people might think are impulsive, risky, or dangerous? If yes, please describe: Does your child have a history of abuse of any kind (sexual, physical, or verbal)?
5 Page 5 of 5 Many people have the following experiences. Please circle any of these that you believe your child experiences more than other children: Difficulty focusing or prioritizing Irritable Overactive/restless Nightmares Do or say things without thinking about the consequences Can t stop thinking about a past experience Anxious Preoccupied with body weight or shape Do things that are harmful to self or others Hear or see things that other people don t hear or see Hot temper Bad memory Feel that people are conspiring against him/her Chronic relationship problems Feel hopeless Thinking about suicide Weight loss/gain Intense highs and lows with his/her mood Experiences that he or she does not understand Homicidal thoughts Overly dependent on others Extreme fear of a specific object, activity, or situation Difficulty telling the truth Getting into physical fights Stressful home conditions Can t slow down thinking Panicky Lack of motivation Going out of my way to avoid things that he or she fears Working too hard Worry about what others might think of him/her Crying/tearful Feel driven to do things over and over Eating problems (i.e., not eating, binging, etc.) Frequent, unwanted thoughts or images Drinking or using drugs If there is any other information you d like to share with me on this form that was not covered in the questions above, please take the space below to do so.
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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
Richard Senysyzn, MD Psychiatry for Adults 1260 River Acres Drive New Braunfels, TX , Fax. (888)
ADHD Evaluation Intake Form Patient Contact Information Patient Name: Date of Birth: Age: Last First MI Address: Email address: Contact phone number: Emergency Contact/Number/Relationship: Pharmacy: Primary
Anxiety Depression Sleep problems Thoughts of suicide. Panic Unusual thoughts Anger outbursts Changes in weight
Client Information Name: Biographical Information Please complete this form, which will provide information useful in treatment. If you are not the patient (for example, if you are giving information about