Omaha Children's Clinic Behavioral Health: New Patient Paperwork

1. Name of person completing form

a. Relationship to patient

2. Child's Full Legal Name

3. Child's Nickname

4. Child's Gender

Male Female Transgender Self-identity Prefer not to say

5. Child's Date of Birth

6. Child/Adolescent's Ethnicity

Hispanic Non-Hispanic

7. Child/Adolescent's Race

African American

Asian-American

Latino/Latina

Native American

Caucasian

Bi-racial

Other

8. Primary Care Physician

9. Name of Referral

10. Main reason you made this appointment

11. Primary caregiver name

a. Relationship to child/adolescent

b. Place of employment & occupation

12. Secondary caregiver name (if applicable)

a. Relationship to child/adolescent

b. Place of employment & occupation

13. Parents are

Married

Divorced

Widowed

Separated

Never Married

Engaged

Other

If other, please specify.

14. Custody arrangement (court-ordered or informal)? If so, what is it?

15. Additional major caregivers

16. Name and ages of siblings

17. Other individuals living in the home

18. How does the child/adolescent get along with their:

Mother

Good Fair Strained Poor

Father

Good Fair Strained Poor

Siblings

Good Fair Strained Poor

Peers

Good Fair Strained Poor

Others

Good Fair Strained Poor

19. Significant events that have occurred in the child/adolescent's life within the past 6 months (e.g. moves, illnesses, changes in family schedule)

20. Did you or the child/adolescent's doctor note any problems with:

Pregnancy

Yes No Unsure

Delivery

Yes No Unsure

Exposure to tobacco or substances (drugs/alcohol) during pregnancy

Yes No Unsure

21. General impression of the child/adolescent's health during infancy

22. Please indicate whether your child/adolescent met the following developmental milestones:

Sat alone (avg 6-8 months)

Delayed Average Above Average Unknown

Crawled (avg 9 months)

Delayed Average Above Average Unknown

Walked (avg 18-18 months)

Delayed Average Above Average Unknown

Fed him/herself (avg 10-12 months)

Delayed Average Above Average Unknown

First words (avg 10 months)

Delayed Average Above Average Unknown

Toilet trained (avg 2-3 years)

Delayed Average Above Average Unknown

23. Do you have concerns with your child's Speech, Motor Skills, Hearing, and/or Vision?

24. Please describe any medical concerns for your child (example: allergies, asthma, diabetes, food sensitivities):

25. Describe any hospitalizations, surgeries, and/or emergency department visits:

26. List any medications and current dosage

27. has your child/adolescent ever received counseling or therapy services?

Yes No Unsure

28. Please explain any therapy received (e.g. who, where, how long, helpful)?

29. Has the child/adolescent ever received inpatient services for mental health?

Yes No Unsure

30. Provide information regarding inpatient services (e.g. when, fow how long, reason for admission):

31. Does the child/adolescent have a history of:

Substance/alcohol use

Legal or offender issues

Victimization (neglect, physical, sexual, emotional abuse)

Witness of abuse (physical, sexual, emotional)

None of these

32. Have any of the child/adolescent's immediate family members had:

Mother

Mental Health Challenges Counseling Services Substance/Alcohol Abuse Legal/Offender Issues None of these

Father

Mental Health Challenges Counseling Services Substance/Alcohol Abuse Legal/Offender Issues None of these

Sibling

Mental Health Challenges Counseling Services Substance/Alcohol Abuse Legal/Offender Issues None of these

Grandparent

Mental Health Challenges Counseling Services Substance/Alcohol Abuse Legal/Offender Issues None of these

Please describe any family mental health concerns:

33. Does the child/adolescent currently attend school or day care?

Yes No

34. Name of your child's school and their current grade or their day care

35. Please provide the name and email of your child's primary school teacher

36. Child/adolescent's current grades

37. Does your child/adolescent have any difficulties with:

Learning

Behavior

Peers

38. Has your child ever been

Suspended

Expelled

Retained

No

39. has your child/adolescent ever received any of the following services?

Early Intervention

Special Education (e.g. IEP)

504 Plan

Resource/Title 1

Other

None

40. Please list any extracurricular activities your child/adolescent is involved in

41. Please indicate some of your child/adolescent's strengths

42. Please indicate some of your child/adolescent's areas for growth

44. Is there anything you would like to discuss with your child/adolescent present?

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