Child/Adolescent Intake Form

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Child/Adolescent Intake Form Today's date: Patient Information: Individual Name: Date of Birth: / / Age: (First) (Last) Gender: Male Female Ethnicity (optional): Name of Person completing this form: Relationship to individual: Years known: Residence of child: (circle one) Biological parents Adoptive parents Foster parents PCS Home Patient Contacts: Other: Mother's name: Age: (First) (Last) Father's name: Age: (First) (Last) Marital Status of Parents: (circle one) Married Divorced Separated Widowed Mother's Address: (street) (city) (state) (zip) Father s Address: (street) (city) (state) (zip) Contact phone numbers: Name/Relationship: Number: Who has legal/physical custody? Type: (please provide legal documentation) Support Services: Does this individual receive services from Health and Welfare? Case Worker: Phone: Services Received: Region:

Presenting Problem: What concerns you most about this individual? When did you first notice this problem? How has this problem affected his/her function? At home: At school/work: Community: Do you have other concerns you want addressed? Have you recently worried that your child has (please circle items relevant to your child): DEPRESSION (sad, irritable, hopeless, poor sleep, crying, social withdrawal/isolative behaviors, lack of interest in things, etc.) MOOD SWINGS (energetic, little sleep, pleasure seeking, racing thoughts, too talkative, inappropriate sexual behaviors, grandiose, etc.) ANXIETY (worries, restless, scared, poor sleep, obsessive thoughts and/or compulsive behaviors, frequent complaining of headaches and/or stomach aches, frequent school absences, etc.) BEHAVIORAL PROBLEM (fights, anger, arguing, truancy, destruction of property, fire setting, etc.) ATTENTION/HYPERACTIVITY PROBLEM (difficulty sustaining attention, hyperactive, impulsive, distractibility, not completing tasks) ABNORMAL EATING BEHAVIORS (too much, too little, fear of weight gain, distorted body image, over exercising, etc.)

SOCIAL ANXIETY (shy and/or afraid to be around others) REMEMBERING PAST TRAUMAS (frequent nightmares, intrusive and/or recurrent memories, etc.) AUTISM (social and language impairments, rigidity) PSYCHOSIS (hearing voices, seeing things, paranoia, delusions) DISSOCIATION (feeling outside your body or things are not real, etc.) Has your child ever harmed themselves intentionally? Attempted suicide? Harmed others? Sleep Patterns: Total hours of sleep per night: Usual Schedule: to Does the individual take naps during the day? If Yes, how many hours in a typical day? Concerns: Current Problem Change within last 6 months Difficulty falling asleep: Frequent awakening: Snoring: Restlessness/Movements: Early morning awakening: Nightmares: Not rested: If yes to any of the concerns listed above, please describe: Past Psychiatric History: Please list any previous psychiatric hospitalizations, residential, or day treatment programs (including any alcohol and drug treatment programs) Diagnosis Length of Stay Treatment Response Please list any current or prior outpatient psychiatrists and therapists your child has seen? Name Title Location How Long? Drug and Alcohol History: Substance Date of Last Use Problems Related to Use Benzodiazepines (Valium, Xanax, Ativan) Caffeine Marijuana Cocaine Designer Drugs (Club Drugs: G, X) Hallucinogens (LSD, Mushrooms) Inhalants (Gasoline, Glue, Aerosol) Methamphetamines (Speed, Ice, Ritalin) Opiates/Methadone (Vicodin, OxyContin, Heroin) OTC Over the counter Treatment Required

(Benadryl, Nyquil, Dramamine) Tobacco: none Amount per day: Anything else we need to know about your drug history: Please list this individual's current medications (psychiatric and non-psychiatric). (You may refer to the list of medications on the next page.) (To ensure accuracy, please take this information directly from your prescription bottles/containers.) Medication Dose Route How Often? What time? Prescriber Please list all the psychiatric medications that have been tried in the past. Medication Dose Duration Response Reason for stopping Do you take over the counter medications or herbal supplements? No Yes (List) Medication Dose Route How Often? What time? Medications: Adderall (dextroamphetamine + amphetamine) Abilify (aripiprazole) Adipex-P (phentermine) Ambien (zolpidem) Amoxapine Antabuse (disulfiram) Anafranil (clomipramine) Aricept (donepezil) Ativan (lorazepam) Aventyl (nortriptyline) Belsomra (suvorexant) Benadryl (diphenhydramine) Buspar (buspirone) Campral (acamprosate) Carbatrol (carbamazepine) Catapres (clonidine) Celexa (citalopram) Chantix (varenicline) Chloral hydrate Clozaril (clozapine) Cogentin (benztropine) Concerta (methylphenidate) Cymbalta (duloxetine) Cylert (pemoline) Dalmane (flurazepam) Depakote /Depakene (valproic acid/ valproate) Dexedrine (dextroamphetamine) Didrex (benzphetamine) Dilantin (phenytoin) Dolophine /Methadose (methadone) Effexor XR (venlafaxine) Elavil (amitriptyline) Ephedra Eskalith (lithium) Evening primrose oil Focalin (dexmethylphenidate) Gabitril (tiagabine) Geodon (ziprasidone) Ginkgobiloba Kappra (levetiracetam) Lamictal (lamotrigine) Latuda (lurasidone) Lexapro (escitalopram) Marplan (isocarboxazid) Meridia (sibutramine) Metadate (methylphenidate) Methylin (methylphenidate) Minipress (prazosin) Moban (molindone) Mysoline (primidone) Nardil (phenelzine) Navane (thiothixene) Neurontin (gabapentin) Norpramin (desipramine) Nortriptyline (Pamelor ) Omega fatty acids Orap (pimozide) Pamelor (nortriptyline) Parnate (tranylcypromine) Paxil (paroxetine) Periactin (cyproheptadine) Prolixin (fluphenazine) Propranolol (Inderal ) ProSom (estazolam) Protriptyline (Vivactil ) Provigil (modafinil) Prozac (fluoxetine) Quillivant (methylphenidate) Remeron (mirtazapine) Restoril (temazepam) ReVia (naltrexone) Risperdal (risperidone) Ritalin (methylphenidate) Rozerem (ramelteon) SAM-e Saint john's wort Sarafem (fluoxetine) Serax (oxazepam) Seroquel (quetiapine) Serzone (nefazodone) Sinequan (doxepin) Sonata (zaleplon) Stelazine (trifluoperazine) Strattera (atomoxetine) Subutex (buprenorphine) Suboxone (buprenorphine + naloxone) Symbiax (olanzapine + fluoxetine) Tegretol (carbamazepine) Tenex (guanfacine) Tenuate (diethylpropion) Thorazine (chlorpromazine) Tofranil (imipramine) Topamax (topiramate) Tranxene (clorazepate) Trazodone (Desyrel ) Trilafon (perphenazine) Trileptal (oxcarbazepine) Valerian Valium (diazepam) Vistaril (hydroxyzine) Vyvanse (lisdexamfetamine) Wellbutrin (bupropion) Xanax (alprazolam) Zarontin (ethosuximide) Zoloft (sertraline) Zonegran (zonisamide) Zyprexa (olanzapine) Zydis (olanzapine)

Family History: Consider this individual's immediate family and all of their relatives on both sides (parents, brothers, sisters, aunts, uncles, grandparents, and 1st cousins) Review the list below if any relative has one of these disorders, check the disorder and describe their relation to your child (such as "Maternal Uncle") and their treatment history (if applicable). Maternal is mother's side of the family and Paternal is father's side of the family. Depression Anxiety ADHD Bipolar (manic depressive) Schizophrenia Alcohol/Drug Problems Learning Disabilities Autism/Asperger/Pervasive Developmental Disorder Mental Retardation "Nervous Breakdown" Psychiatric Hospitalizations Suicide (or attempts) Panic Disorder PTSD (Post Traumatic Stress Disorder) OCD (Obsessive Compulsive Disorder) Seizures Migraines Heart or lung problems Thyroid Immunological disorders (lupus, scleroderma, inflammatory bowel disease) Cancer Other Developmental History: Did your child achieve the following milestones early (E), average (A), or late (L) compared with other children his/her age (please explain if late): Language (age at first using words, sentences, etc. )? Fine motor skills (building towers with cubes, drawing circle) Gross motor skills (rolling over, standing, walking)? Toilet training? Has your child experienced any regression of these? If yes, explain: Pregnancy and Birth History: How old was this child's biological parents when he/she was conceived? Was this the biological mother's first pregnancy? If no, how many times was she pregnant before this pregnancy? Did the biological mother experience any miscarriages before or after this pregnancy? If yes, how many? During what trimester? When was prenatal care first received (in weeks): How much weight did the biological mother gain during this pregnancy?: Baby's birth weight and length: Length of pregnancy (in weeks): Did the mother have any ultrasounds or amniocentesis? If yes, please describe the reason for these and the results: Please indicate whether any of the following events/problems occurred during this pregnancy. Please

include the trimester in which the event occurred, as well as any other important details. Yes / No # of months into Additional details pregnancy Infections/Colds Fevers Hospitalizations Vaginal bleeding, spotting Problems with diet Pregnancy induced Hypertension High blood pressure, excessive swelling Diabetes Rh or Blood Incompatibilities Trauma (emotional stress and/or physical injury) Did you take any medications (prescription and over the counter) during this pregnancy? (If yes, please complete the following table.) Medication Month(s) taken Dose Reason for taking (1-9) Did you consume alcohol during this pregnancy? If yes, how much and how often? Did you smoke or use tobacco products during this pregnancy? If yes, please describe how much and how often? Did you use any drugs during this pregnancy? If yes, please name drug(s), how much and frequency of use: Labor Information: Type of delivery (c-section, vaginal): Were forceps used? Were there any problems with the baby's health right before or immediately after delivery? Were the mother and/or baby separated after birth for more than 24 hours at a time? If yes, please explain: Past Medical History: Primary Care Provider: Years Involvement: Phone: Address: Approximate Date of Last Visit: Number of Visits in Last Year: Other Provider(s): Specialty: Name: Phone: Address: Other Provider(s): Specialty: Name: Phone: Address: Allergies (drug, food, seasonal, environmental etc.)? If yes, please name and describe your child's reaction: Has your child ever experienced a head injury, loss of consciousness, or seizure? Does your child have any chronic medical problems?

Does your child have a history of any serious injuries or medical hospitalizations? Does your child have chronic pain (frequent headaches, stomachaches, chest pain)? Do you have any concerns related to your child s balance or ability to walk? Has your child had a significant unintentional or unexpected fall in the past year? (consider referral to STARS if yes) In the past year, has your child lost or gained weight without meaning to? How much and in what time frame? How many meals a day does your child eat? Have you recently worried that your child may have problems with: Heart Constipation/Diarrhea Age of first menses Lungs Frequent infections Regular or Irregular cycle Kidneys/Bladder Endocrine (i.e., diabetes; thyroid dysregulation; excessive hair growth) Neurological Immunizations up to date Has your child ever had an EEG, MRI, CT SCAN, etc? If yes, why was it done and were the results normal? If yes, where were the tests performed and who ordered them? Social History: Is your child your biological child? If no, at what age was he/she adopted? Is there any contact with their biological parent(s)? Where was your child born and raised? Allergies (drug, food, seasonal, environmental etc.)? If yes, please name and describe your child's reaction: Has your child ever experienced a head injury, loss of consciousness, or seizure? Does your child have any chronic medical problems? Does your child have a history of any serious injuries or medical hospitalizations? Does your child have chronic pain (frequent headaches, stomachaches, chest pain)? Do you have any concerns related to your child s balance or ability to walk? Has your child had a significant unintentional or unexpected fall in the past year? (consider referral to STARS if yes) In the past year, has your child lost or gained weight without meaning to? How much and in what time frame? How many meals a day does your child eat? Have you recently worried that your child may have problems with: Heart Constipation/Diarrhea Age of first menses Lungs Frequent infections Regular or Irregular cycle Kidneys/Bladder Endocrine (i.e., diabetes; thyroid dysregulation; excessive hair growth) Neurological Immunizations up to date

Has your child ever had an EEG, MRI, CT SCAN, etc? If yes, why was it done and were the results normal? If yes, where were the tests performed and who ordered them? Social History: Is your child your biological child? If no, at what age was he/she adopted? Is there any contact with their biological parent(s)? Where was your child born and raised? Has your child moved a number of times? If yes, please list their age at time of move and location: Parents: (Including Step-Mother and Step-Father, if applicable) Name Education Occupation Hrs/Wk Relationship with Child (quality) Please list the other children in the family and other household members who may also be living in your home: Name Age Lives at Home? Relation to Child Relationship with Child Abuse History: Has your child ever been the victim of abuse or neglect? If yes, what was the nature of the abuse? (Please circle all that apply.) Physical Emotional Neglect Accidents Disasters Sexual

Witnessing violence Other Are you struggling with your marital relationship or parenting? Has your child ever been involved with the following and if yes, please explain: Child Protective Services Childrens Mental Health Probation/Juvenile Probation/Detention Boys and Girls Club Youth Services Head Start Early Intervention Services (ages 0-3) School: Where does your child attend school? In what grade level is he/she? What are his/her typical grades? What are your child's academic strengths? Academic weaknesses? Has there been a change in your child's performance at school? Has your child received IQ or Academic testing? If yes, what were the results? Does or has your child participated any of the following? Resource (for which classes/how many hours?) Accelerated or Honors programs, explain: 504 Plan, explain: Individual Education Plan (IEP), explain: Virtual Academy, explain: Has your child had problems with any of the following? Truancy, explain: Fights, explain: Absenteeism, explain: Detention, explain: Suspension, explain: School refusal, explain: What are your child's favorite activities? How does your child learn best? Verbal explanations Written informational handouts

Other Does your child have any significant problems that might affect learning? (Such as, trouble seeing or hearing, difficulty in understanding, speaking a different language, other) Peers: Does your child have quality relationships with other children? If no, please explain: Culture: Do you have a religious preference in the household? If yes, what is that preference? Has your child experienced any problems related to race, religion, or culture? If yes, please explain: TEEN/YOUNG ADULT SECTION Do you have any concerns regarding your adolescent's friendships? (Please circle all that apply.) Too old Too young Truant Gang Fringe Drug/alcohol use Violence Too many Too few Sexual Promiscuity Too much time together Other Has your adolescent had a recent change in friendships? If yes, what changes, if any are concerning to you? Are you concerned that your adolescent is using (or has used) drugs (including over the counter medicines) or alcohol? Are you concerned about your child's sexual activities? Is your adolescent sexually active? Does your adolescent have a job? Has your adolescent's behavior ever resulted in police, detention, or court involvement? Yes No If yes, please explain:

Is there anything else you would like us to know about your child?

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