Child and Youth Background Information
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- Magdalene Sims
- 5 years ago
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1 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 apply: Substance Frequency Amount Tobacco Caffeine Alcohol Cocaine/ Crack Ecstasy Heroin Inhalants Methamphetamines Pain Killers PCP/ LSD Steroids Tranquilizers Marijuana Has your child had withdrawal symptoms when trying to stop using any substances? If yes, please describe: Has your child ever had problems with work, relationships, health, the law, etc. due to his/her substance use? If yes, please describe: PREVIOUS MENTAL HEALTH TREATMENT If yes: Dates of Treatment: From To Provider/Program 2012 Advance Potential Psychological Services Child and Youth Background Info Page 1 of 5
2 Type of Treatment: Outpatient Counseling Psychiatric Hospitalization Self-help/Support Groups Medication (mental health) Drug/Alcohol Treatment Primary Care Physician & Medical Care Current Physician: Physician Address: Primary Care Physician Phone #: ( ) Fax #: ( ) Emergency Contact: Medical: MEDICAL INFORMATION Date of last physical exam: Has your child experienced any of the following medical conditions during his/her lifetime? Allergies Asthma Headaches Stomach Aches Chronic Pain Surgery Serious Accident Head injury Dizziness/fainting Meningitis Seizures Vision problems High Fevers Diabetes Hearing problems Miscarriage Sexually Transmitted Disease Abortion Sleep Disorder Other (please list): Please list any CURRENT health concerns: Current prescription medications: Medication Dosage: Date First Prescribed: Prescribed By: Current over-the-counter medications (including vitamins, herbal remedies, etc.): Please list any allergies and/or adverse reactions to medications: 2012 Advance Potential Psychological Services Child and Youth Background Info Page 2 of 5
3 SCHOOL INFORMATION Current grade/placement: This year s school grades: Excellent Good Fair Poor Past school grades: Excellent Good Fair Poor This year s school behavior: Excellent Good Fair Poor Past school behavior: Excellent Good Fair Poor Has your child had any of the following difficulties at school? Suspension Incomplete homework Learning problems Referrals or detentions Poor grades Teased or picked on Speech problems Attendance problems Gang influence Does your child have an after-school provider? Yes No If so, who? Has your child ever repeated a grade? Skipped a grade? Yes No If yes, which one(s)? Has your child ever received Special Education services? If yes, please describe services received and reason for services: What does your child s teacher(s) say about him/her? FAMILY AND DEVELOPMENTAL HISTORY CHILD S NAME: Include everyone who lives with the child: Name of Person Relation to Child Age of Person Quality of Relationship With Child (Good, Fair or Poor) 2012 Advance Potential Psychological Services Child and Youth Background Info Page 3 of 5
4 Is there a family history of mental health problems? If yes, who? Mother Father Stepmother Stepfather Siblings Other Relatives Hyperactivity Sexual Abuse Depression Manic Depression Suicide Anxiety Panic Attacks Obsessive-Compulsive Anger/Abusive Schizophrenia Eating Disorder Alcohol Abuse Drug Abuse Parents legally married Living together Parents divorced Permanently separated Parents temporarily separated Father remarried: Number of times Mother remarried: Number of times Please check if your child has experienced any of the following types of trauma or loss: Emotional Abuse Neglect Lived (lives) in a Foster Home Sexual Abuse Violence in the Home Multiple Family Moves Physical Abuse Crime Victim Homelessness Parent Substance Abuse Parent Illness Loss of a Loved One Teen Pregnancy Placed Child for Adoption Financial Problems Were there any medical problems during the pregnancy or birth of your child? If yes, please describe: Did the biological mother use any tobacco, medication, street drugs, or alcohol while pregnant with this child? If yes, please describe substances used, quantity, and frequency: Substance Frequency Amount Tobacco Caffeine Alcohol Cocaine/ Crack Ecstasy Heroin Inhalants Methamphetamines Pain Killers PCP/ LSD Steroids Tranquilizers Marijuana 2012 Advance Potential Psychological Services Child and Youth Background Info Page 4 of 5
5 Did your child have any developmental delays in early childhood (crawling, walking, talking, toileting, etc.)? If yes, please describe: INTERPERSONAL/SOCIAL/CULTURAL INFORMATION Please describe your social support network (check all that apply): Family Neighbors Friends Students Co-workers Support/Self-Help Group Community Group Religious/Spiritual Center (which one?): To which cultural or ethnic group does your child belong? If your child is experiencing any difficulties due to cultural or ethnic issues, please describe: LEGAL INFORMATION If the parents are separated or divorced, what is the current child custody/visitation arrangement? Is your child currently the subject of a custody case? Has your child ever been a ward of the court with DCFS guardianship? Does your child have any legal offenses on record or pending in the courts? Yes No 2012 Advance Potential Psychological Services Child and Youth Background Info Page 5 of 5
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
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
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
PATIENT INFORMATION Demographic Information Form / / Mailing: Male Female SSN#: - - Home Cell Relationship Status (circle one): Single / Married / Divorced / Widowed / Other: ( ) - ( ) - (Preferred Phone
*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
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
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:
2550 Middle Road, Suite 316 Bettendorf, Iowa Adult Intake Form
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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:
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
PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT
DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she
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
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
CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake)
CHILD/ADOLESCENT SELF-REPORT FORM (To be completed before initial intake), LLC 2383 University Ave West, Suite 200 Saint Paul MN 55114 Phone: 651-644-4100 Fax: 651-644-4100 Date: Form Completed By: Relationship
PATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient)
NAME: DOB: Today's date: PATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient) Use the opposite side of the page as necessary to complete your answers. Please print legibly. Patient Name
PATIENT IDENTIFICATION: Name: First Appointment Date: Birth Date: Address: City State Zip Home Phone #: Work #: Cell #: REFERRAL SOURCE: Referred By:
Andrew E. Leifer, M.D., P.C. 1202 Bergen Parkway, Suite 211 Evergreen, Colorado 80439 General Adult Psychiatry Outpatient and Hospital Care Medical Consultation-Liaison Service Telephone (303) 674-6074
Name Age Relationship to patient
Clackamas Pediatric Clinic Oregon Pediatrics Meridian Park 8645 SE Sunnybrook Blvd #200 19260 SW 65 th Ave #275 Clackamas, OR 97015 Tualatin, OR 97062 (503) 659-1694 (503) 691-2519 Oregon Pediatrics Happy
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:
If so, when: Demographic Information Male Transgender Height: Weight: Massachusetts Resident? Primary Language: Are you currently homeless?
Application Form rev. 9/09 Jeremiah's Inn P.O. Box 30035 1059 Main St., Worcester, MA 01603-0035 FAX 508.793.9568 Phone 508.755.6403 Last Name: Suffix: First Name: Middle Initial: Alias: Referral Information
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
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
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ADULT INTAKE/PSYCHOSOCIAL ASSESSMENT Name: Date: Referred by: Date of Birth: SSN: Identifying Information (age, marital status, ethnicity, and sex) 1. Reason for Referral: (Why are you here? Describe problems,
Child s name: Nickname: Date of Birth: / / Sex: Male Female SSN: Today s date: / / Parent s Name #1: Home phone: ( ) Cell: ( )
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Elana Klemm, LPC, NCC Compassionate Care Counseling 4343 Shallowford Rd. Suite H-1B Marietta, GA ( ) NEW CLIENT INFORMATION
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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
Comprehensive Screening (adult)
Comprehensive Screening (adult) Patient Name: _ DOB: / / Today s Date: / / Which type of visit does your daughter need today? Address a specific symptom or issue Medication questions/refills (list meds)
Preferred Name (s): Local Address: City: State: Zip: Permanent Address: City: State: Zip: Years of Education: Occupation: Gender: M F
Today Date: Client Name(s) : Psychological Consultants Northgate Center 1210 ½ -7 th Street NW, Suite 216 Rochester, MN 55901 www.psychologicalconsultants1.com Office: (507) 252-9292 Fax: (507) 252-9203
Lake Psychological Services, LLC
Lake Psychological Services, LLC Welcome to Lake Psychological Services and thanks for choosing our office for your health care needs. Seeking treatment is not an easy decision and you may have questions
CLIENT INTAKE FORM. Please describe your main reason(s) for seeking services at this time?
KARI KOKKO, MSW, RSW CLIENT INTAKE FORM Client Name: Please describe your main reason(s) for seeking services at this time? CURRENT RELATIONSHIP STATUS Single Common Law Separated Widowed Cohabitating
Physical Issues: Emotional Issues: Legal Issues:
Men s Facility 1119 Ferry Street Lafayette, IN 47901 Phone: (765) 807-0009 Fax: (765) 807-0030 Hope Apartments 920 N 11th St. Lafayette, IN 47904 Phone: (765) 742-3246 Fax: (765) 269-9110 APPLICATION FOR
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York (914)
Joan B. Jablow, APMHNP 45 Byram Lake Road Mt. Kisco, New York 10549 jablownp@optimum.net (914) 241-1246 Personal Adult (18+) Client s name: Date: Gender: F M Date of birth: Age: Address: City: State: Zip: