Behavioral Health (English)

Patient Information

Patient Name:

Email Address:

Nickname:

Home Address:

Date of Birth:

Age:

Phone:

Sex:

Male Female

Cell Phone/Work Phone:

Ethnicity (check all that apply):

African-American

Asian-American

Hispanic

Native American

White/Caucasian

Other

Religious Preference:

Referral Information

Patient's Physician:

Who referred patient to the clinic?

Is it okay to have reports mailed to the Physician?

Yes No Unsure

Reason for Referral / Primary Concerns:

Family Information/Patient Background Information

Biological parents are: (Please provide date below, except if selected "Never Married".)

Married Divorced Separated Never Married

Patient resides with:

Mother

Father

Mother's Name:

Circle One

Biological Adoptive Step Foster/Guardian Other

Age:

Occupation:

Employer:

Work Schedule:

Father's Name:

Circle One

Biological Adoptive Step Foster/Guardian Other

Age:

Occupation:

Employer:

Work Schedule:

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

Add new row

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

Add new row

Please list previous residences (city & state) and length of time lived there:

Any problems/stressors in the family in the last year? (for example, death in the family, move, parental/marital conflict, financial stressors, accidents/traumatic events)

Medical/Developmental Information

Were there any problems with pregnancy or delivery?

Yes No

If yes, please explain:

Were there any concerns with drug/alcohol abuse, cigarette use, high blood pressure during pregnancy?

Yes No

What is your general impression of your child’s infant development?

Good Fair Poor

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)

Sat alone:

Crawled:

Walked:

Fed Self:

Spoke Words:

Toilet Trained:

Any problems with the patient’s vision?

Normal Abnormal Corrected

Any problems with the patient’s hearing?

Normal Abnormal Corrected

Any problems with the patient’s speech?

Normal Abnormal Corrected

Any problems with the patient’s motor skills?

Normal Abnormal Corrected

Circle all conditions in which this child has had or currently has:

Allergies

Asthma

Cancer

Diabetes

Genetic Condition

Seizures

Other medical conditions/health concerns:

Current Medications

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Has the patient ever received medications, counseling/psychotherapy for behavioral/emotional concerns?

Yes No

If yes, describe problems, medications, therapist, and dates:

Family Health History

Has either parent or other family members received medication, counseling/psychotherapy?

Yes No

If selected "Other", please provide details:

School Information

Child attends daycare?

Yes No

If yes, please provide name of daycare/child care provider.

Child attends school?

Yes No

Grade

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

School:

Teacher’s Name:

Child’s current grades are:

Grades last semester were:

Has the patient ever been suspended, expelled, or retained in a grade?

Yes No

If yes, when?

Have you had special conferences or extra meetings with teachers or school administrators for your child’s behavior or learning problems?

Yes No

If yes, when?

Has the patient ever had an IEP, 504 Plan, or other Special Education Services? (for example, learning disability, behavioral/emotional disorder class, speech/language services, resource room)

Yes No

Behavioral Health Information

Describe the best things about your child?

List the clubs/groups and favorite activities of your child:

Does your child have a bedtime routine?

Yes No

What time does your child typically go to bed?

What time does he/she typically fall asleep?

What time does he/she wake up in the morning?

Does the patient snore loudly?

Yes No

Does the patient typically wake up in the middle of the night?

Yes No

Does the patient typically take a nap each day?

Yes No

If yes, how long?

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

Won't Mind

Never Some Often Always

Too active

Never Some Often Always

Anger

Never Some Often Always

Clumsy

Never Some Often Always

Destructuve

Never Some Often Always

Easily Upset

Never Some Often Always

Toileting problems

Never Some Often Always

Impulsive

Never Some Often Always

Suicidal Thoughts

Never Some Often Always

Nervous

Never Some Often Always

Cries a lot

Never Some Often Always

Harms self

Never Some Often Always

Very shy

Never Some Often Always

Clings to parent(s)

Never Some Often Always

Nightmares

Never Some Often Always

Aggressive to others

Never Some Often Always

What concerns you most about your child?

Please provide any other information you would like to discuss during your child’s upcoming appointment.

Has your child been the a victim of any physical, emotional or sexual abuse?

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