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1 DEPARTMENT OF PSYCHIATRY Tuesday, Division of March Child and 14, Adolescent 2017 Psychiatry 8491 NW 39 th Ave. Gainesville, FL Phone: Fax: Welcome and thank you for choosing University of Florida Physicians! Dear Parent/Guardian, the information you provide here will help your provider in identifying your child s needs and how to best serve your family. Please be prepared to arrive 30 minutes early to complete clinic paperwork upon arrival. If you cannot keep this appointment, please call to cancel as soon as possible. If you fail to do so, you may not be allowed to reschedule your appointment. Please complete the attached assessment forms prior to your appointment. Please bring your completed paperwork, updated insurance information and any current medications in their original bottle to your appointment. The Child and Adolescent Psychiatry Clinic is located at 8491 NW 39th Ave. If you have any questions or need to reschedule, please call (352) Thank you for choosing UF Health for your healthcare needs and we look forward to serving you! PARENT OR GUARDIAN: PLEASE COMPLETE AND BRING THIS FORM TO CLINIC 1
2 Who referred you to our clinic? DEMOGRAPHICS: Name of the person completing this form: Relationship to the child: Child s Full Legal Name: Is there another name the child prefers being called? Child s Date of Birth: / / Age: Gender: Race: Religion: Is the child adopted? No Yes If yes, are they aware? No Yes Who lives in the same household as the child? Name Sex Age Relationship to Child Parent(s) occupation: 2
3 What are the main concerns that you have about your child? How long have you had these concerns? What are your goals for treatment of your child? Please circle all of the following symptoms that apply to your child: Sad or depressed mood Withdrawn from family or friends Loss of interest in activities or hobbies Feelings of guilt or worthlessness Feeling hopeless about the future Sleep disturbance Change in appetite Low energy or fatigue Trouble focusing or concentrating Thoughts of hurting self Thoughts of suicide Thoughts of hurting or killing others Drastic mood swings Episodes of decreased need for sleep Extreme hyperactivity Racing thoughts Talking so fast it s hard to understand Overly happy or euphoric Overly confident Hearing voices that other people cannot hear Seeing things other people cannot see Feeling paranoid Odd thinking or beliefs Irritability Severe angry outbursts (verbal or physical) Worrying too much Feeling or acting restless Muscle tension Panic or anxiety attacks Fear of looking stupid or being embarrassed Fear of offending others Any other fears or phobias Thoughts, feelings or pictures that come into the child s mind even if he/she does not want them to? Habits the child feels they must do even if he/she knows it does not make sense (for example excessive cleaning, checking, repeating, counting, organizing or hoarding things)? Poor body image Trying to lose weight even though he/she is not overweight Intentionally throwing up after eating 3
4 Easily loses temper Easily annoyed Defiant Argues with authority figures Annoying others on purpose Blaming others for his/her mistakes Resentful, spiteful or vindictive Lying Stealing Destroying property Setting fires Skipping school Hurting other people or animals Difficulty learning Trouble understanding social cues Difficulty forming or keeping friendships Being very sensitive to sound, light, touch or smell Tics, twitches or involuntary movements Making involuntary sounds Traumatic experiences: Has your child ever been exposed to actual or threatened death, serious injury, or sexual violence? No Yes If yes, does he/she have any of the following symptoms related to the traumatic event? Upsetting or intrusive memories Nightmares Flashbacks (feeling or acting like the event is happening again) Avoiding talking or thinking about what happened Feeling upset by reminders of the event Having out of body experiences Feeling like the world/surroundings are not real Angry outbursts Recklessness or self-destructive behavior Getting startled very easily Always looking around for signs of danger Trouble remembering some or all of what happened PAST PSYCHIATRIC HISTORY: Has your child ever seen a psychiatrist or therapist/counselor before? Name of provider Dates seen Reason 4
5 Has your child ever been admitted to a psychiatric hospital? Name of the hospital Dates Reason Has your child ever attempted suicide? No Yes If yes, please describe: Does your child engage in any self-harm behaviors (like cutting)? No Yes describe: If yes, please Has your child ever been violent or aggressive? No Yes If yes, please describe: FAMILY HISTORY: Please list any known psychiatric illnesses in blood relatives of the child: Psychiatric illness: Child s Mother Child s Father Child s siblings Depression Anxiety Bipolar disorder Psychosis Schizophrenia ADHD Intellectual disability or learning problems Autism Eating disorder Alcohol problems Drug problems Suicide Mother s side of the family Father s side of the family Does the child have any blood relatives with heart defects or arrhythmias? No Yes Unknown Does the child have any blood relatives who died suddenly at a young age? No Yes Unknown SUBSTANCE USE HISTORY: Does the child use: Alcohol Tobacco Illegal drugs Specify: 5
6 MEDICAL HISTORY: Does your child have any history of the following medical conditions (circle all that apply)? Allergies (describe) Loss of Consciousness Asthma Heart problems Respiratory Illness High Blood Pressure Diabetes Low Blood Pressure Convulsions/Seizures/Epilepsy Urogenital Problems Head Injury Vision Problems Dizziness or Fainting Hearing problems Any other serious illness or disease? Has your child ever had surgery? No Yes If yes, describe and give dates: Has your child ever had any serious injuries? No Yes If yes, describe and give dates: Biological females only: Has your child started menstruation? No Yes If yes, at what age Are periods regular? No Yes Date of last menstrual cycle / / Is there any change in symptom severity with periods? No Yes If yes, please describe MEDICATIONS: Please list all medication your child is currently taking: Name of medication Dose of medication Who prescribes it? 6
7 Please circle any medications your child has taken in the past: Alprazolam (Xanax) Diazepam (Valium) Mirtazapine (Remeron) Amitriptyline (Elavil) Duloxetine (Cymbalta) Nortriptyline (Pamelor) Amphetamine (Adderall) Escitalopram (Lexparo) Olanzapine (Zyprexa) Aripiprazole (Abilify) Fluoxetine (Prozac) Oxcarbazepine (Trileptal) Asenapine (Saphris) Fluphenazine (Prolixin) Paliperidone (Invega) Atomoxetine (Strattera) Fluvoxamine (Luvox) Paroxetine (Paxil) Bupropion (Wellbutrin) Guanfacine (Intuniv) Quetiapine (Seroquel) Buspirone (BuSpar) Haloperidol (Haldol) Risperidone (Risperdal) Carbamazepine (Tegretol) Iloperidone (Fanapt) Sertraline (Zoloft) Citalopram (Celexa) Imipramine (Tofranil) Topiramate (Topamax) Clomipramine (Anafranil) Lamotrigine (Lamictal) Trazodone (Desyrel) Clonazepam (Klonopin) Levomilnacipran (Fetzima) Valproic Acid (Depakote) Clonidine (Kapvay) Lisdexamfetamine (Vyvanse) Venlafaxine (Effexor) Clozapine (Clozaril) Lithium Vilazodone (Viibryd) Desipramine (Norpramin) Lorazepam (Ativan) Vortioxetine (Brintellix) Desvenlafaxine (Pristiq) Loxapine (Loxitane) Ziprasidone (Geodon) Dexmethylphenidate Lurasidone (Latuda) Other: (Focalin) Amphetamine (Adderall) Methylphenidate (Aptensio, Concerta, Daytrana, Metadate, Methylin, Ritalin, Quillivant) ALLERGIES (circle): No Known Drug Allergies Other: Please list any allergies the child has: SOCIAL HISTORY: Name of child s current school: Current grade: Did the child repeat any grades? No Yes Does the child have a 504 plan or IEP? No Yes Is the child in ESE or special needs classes? No Yes Has the child ever been suspended or expelled? No Yes Does the child get bullied by peers? No Yes Has the child ever been the victim of abuse? No Yes Has the child been arrested? No Yes Are there any weapons or guns in your home? No Yes If so, does your child have access to them? No Yes 7
8 DEVELOPMENTAL HISTORY: (Not all parents remember the answers to these questions. You can write down what you do remember or look back if you kept a baby book.) What was the length of the pregnancy? Were any medications or substances used during pregnancy? No Yes If yes, what? Any other complications of pregnancy or delivery? No Yes How much did the baby weigh at birth? Did the baby start breathing right away? No Yes Were there any problems with the baby after he/she was born? No Yes When did the baby leave the hospital? When the baby came home, were there any problems? No Yes When did the baby really smile (not gas )? When was the baby able to sit by him/herself (without help)? When did the baby walk by him/herself (without holding on)? When did baby say his/her first word? When did the baby say short sentences (such as go bye bye )? Did the child have trouble learning to speak? Was he/she different from brother or sister or other children? Is the child toilet trained? No Yes If yes, how old when trained? How old was the child when he/she was able to: When did the child learn to ride a tricycle? When did the child learn to ride a bicycle without training wheels? When was the child able to get dressed by him/herself? When was the child able to tie shoelaces? What hand does the child prefer to use? Right Left No Preference At what age did you notice this? Did anything else significant occur during the child s development years? TESTING HISTORY: Did the child ever have IQ or achievement testing? No Yes Has the child been tested for hearing abnormalities? No Yes Has the child been tested for speech/ language abnormalities? No Yes Has the child ever received occupational or physical therapy? No Yes OTHER: Has the child experienced any of the difficulties below? Please circle all that apply: Death of a parent, Death of other loved ones/close friend, Separation from parent or family, Parent separation/divorce, Loss of Home, Family financial problems, Parent with substance abuse problem, Conflicts with parents, Removal of child from home, Victim of crime or violence, Unwanted pregnancy, School problems, Illness in self, Illness in family (specify), Other: 8
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A Adderall Counterfeit, 31 addiction, internet CBT, 55 ADHD Adjunctive Guanfacine, 11 Counterfeit Adderall, 31 Developmental Trajectory and Risk Factors, 5 Dopamine Transporter Alterations, 14 Extended-Release
All formulary medications available in generic form are supplied in generic form. Requests for brand name preparations must get prior authorization.
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Thank you for choosing Pine Rest Christian Mental Health Services. We look forward to providing services to you.
Thank you for choosing Pine Rest Christian Mental Health Services. We look forward to providing services to you. In order to make the most of your first appointment, please come at least 30 minutes prior
Psychiatric Evaluation Intake Form
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ALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY
ANTIDEPRESSANTS Serotonin Selective Reuptake Inhibitors citalopram 10, 20, 40 mg, 10 mg/5cc $ 0.40 No escitalopram 10, 20 mg $ 2.60 Yes fluoxetine 10, 20 mg, 20 mg/5 ml $ 0.40 Yes fluvoxamine 25, 50, 100
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DEPRESSION. Men and women of all ages, races, and economic levels can have depression. It occurs more often in women.
DEPRESSION The exact cause of depression is not known. Many researchers believe it is caused by chemical imbalances in the brain, which may be hereditary or caused by events in a person's life. Some types
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:
Medications for Anxiety & Behavior in Williams Syndrome. Disclosure of Potential Conflicts. None 9/22/2016. Evaluation
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#55 PRESCRIBING AND MONITORING PSYCHI RIC MEDICATIONS
- '_ ADMINISTRA TIVE/FISCAUCLINICAL/PHF POLICY AND PROCEDURES COUNTY OF SANTA BARBARA ALCOHOL, DRUG AND MENTAL HEAL TH SERVICES Section - QUALITY ASSURANCE Effective: 12/1/09 Policy- Director's Approval
Prepared by: Elizabeth Vicens-Fernandez, LMHC, Ph.D.
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Depression. There are several forms of depression (depressive disorders). Major depressive disorder and dysthymic disorder are the most common.
Depression Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and sense of well-being. People with depressed mood can feel sad, anxious,
Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 05/01/2015
Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 05/01/2015 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority
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Title 19/21 GMH/SA & Non-Title 19/21 SMI Behavioral Health Drug List Updated 01/01/2017 Effective April 1, 2014, Mercy Maricopa Integrated Care began operations as the Regional Behavioral Health Authority