Behavioral Health (English)

Please complete the following information prior to your child’s first appointment with Dr. Collin Dean, PsyD.

Please correct the errors described below.

Patient Information

Referral Information

Family Information/Patient Background Information


Other Members of the Household (for example, siblings, step-siblings, foster children):

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Other Regularly Involved Adults (for example, grandparents, non-custodial parents/step-parents):

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Medical/Developmental Information


Note the month in which your child achieved the following activities:
(Normal development: Sit 6-8 mos; Crawl 9 mos; Walk 12-18 mos; Feed 10-12 mos; Speak 10 mos; Toilet 24-36 mos)


Current Medications

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Family Health History

School Information

(If summer, what grade will child be entering.)

Behavioral Health Information


Which of the following have recently been or currently are problems with your child?

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