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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 Valley Oregon Pediatrics NE Portland 15970 SE Misty Dr. #100 5050 NE Hoyt St. #B55 Happy Valley, OR 97086 Portland, OR 97213 (503) 427-2637 (503) 233-5393 Central Fax (503) 659-8984 Patient Accounts (503) 427-2118 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

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

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

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

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

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

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