Lakeview Medical and Psychiatric Healthcare Child Form

Dear Future Client, we wanted to extend our heartfelt gratitude to you for taking the time to complete our new intake form. Your willingness to share essential information about your health and needs is invaluable and greatly appreciated. Your thoroughness in providing us with this information will enable us to better understand your unique circumstances and tailor our services to meet your specific needs. Your commitment to your own well-being is a testament to your proactive approach to healthcare, and it is a pleasure to have you as a patient. Please know that your trust in our practice is not taken for granted, and we are here to support you every step of the way. If you have any questions or need further assistance, please don't hesitate to reach out. Your health and comfort are our top priorities. Once again, thank you for your time and cooperation. We look forward to working with you to provide the best possible care and support for your mental health. Warm regards, Lakeview Crew

Prior to completing form please confirm our providers are in your insurance network with your insurance company. If not we do offer a self pay option.

This form helps us learn about your medical and psychiatric history. Please complete it to the best of your ability. Not every question is relevant to everyone. If you feel uncomfortable answering a question, leave it blank.

309-575-3222
macomblakeview@hush.com

Child's Name

Legal first and last name

Date of Birth

Age

Gender

Male Female

Current Grade in school if applicable.

Form completed by:

Contact information, if applicable please provide, name, phone, and email address below:

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Family History

Parents

With whom does the child live with at this time?

Who currently has legal custody of the child?

Were the parents ever married?

Yes No

ls there any significant information about the parents' relationship or treatment toward the child which might be beneficial in counseling?

Yes No

If yes, please describe below.

Client's Mother

Name

Legal first and last name

Age

Occupation

Location of employment

Hours worked per week

Mother's education

Is child currently living with mother?

Yes No

Is there anything notable, unusual, or stressful about the client's relationship with the mother?

Yes No

If yes, please explain below:

How is child disciplined by the mother?

For what reasons is the child disciplined by the mother?

Client's Father

Name

Legal first and last name

Age

Occupation

Location of employment

Hours worked per week

Father's Education

Is child currently living with father?

Yes No

Is there anything notable, unusual, stressful about the client's relationship with father?

Yes No

If yes, please explain below:

How is child disciplined by the father?

For what is the child disciplined by the father?

Client's siblings and others who live in the household

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Others living in the household

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Additional Comments

What are the family's favorite activities?

How are problems generally handled?

Has the child ever experienced physical, sexually abuse or neglect?

Yes No

If yes, please describe below:

Has the child ever experienced death of friends, family, pets, other?

Yes No

If yes, what age?

If yes please describe below the child's reaction?

Has there been any other significant events in child's life (moving, fire, family, etc)?

Yes No

If yes, please describe below:

Early Childhood History

Pregnancy/Birth

Has the child's mother had any occurrences of miscarriages or stillborns?

Yes No

If yes, please describe below:

Was the pregnancy planned?

Yes No

Length of pregnancy?

Mother's age at child's birth

Father's age at child's birth

While pregnant did the mother smoke?

Yes No

If yes, type/what ammount?

While pregnant did the mother use drugs/alcohol?

Yes No

If yes, type/what ammount?

While pregnant, did the mother have any medical or emotional difficulties? e.g. surgery, hypertension, medication

Yes No

If yes, please describe below:

Length of labor

(in hours)

Induced

Yes No

Caesarean

Yes No

Baby's birth weight:

Baby's birth length:

Please describe any physical/emotional complications with delivery below:

Please describe any complications for the mother or baby after the birth:

Length of hospitalization for mother:

Length of hospitalization for baby:

Infancy/Toddlerhood

Developmental History

Please note the age at which of the following behaviors took place

Sat alone

months

Took first steps

months

Spoke words

months

Spoke sentences

months

Dressed self

years

Tied shoe laces

years

Road two-wheeled bike

years

Potty trained

years

Weaned

months

Fed self

months

Dry during day

years

Dry during night

years

Age for the following developments (fill in where applicable):

Began puberty

years

Menstruation

years

Voice Change

years

Convulsions

years

Breast development

years

Injuries or hospitalizations

years

Issues that affected child's development

e.g. inadequate nutrition, neglect, etc.

Medical/Physical Health

List any current health concerns:

List any recent health or physical changes:

Is child currently taking any medications, supplements, herbal remedies?

Yes No

If yes please include all current prescribed, over the counter, supplements and/or herbal remedies used below:

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Name of pharmacy used

Immunization Record: has the child received all immunizations?

Yes No

Name of current primary care provider

Phone Number:

Nutrition

Breakfast

Eats breakfast:

days per week

List of typical foods eaten:

Lunch

Eats lunch:

days per week

List of typical foods eaten:

Dinner

Eats dinner:

days per week

List of typical foods eaten:

Snacks

Eats snacks:

days per week

List of typical foods eaten:

Comments regarding nutrition:

Describe any concerns regarding your child's weight or eating habits:

Education

Current School:

Grade

Teacher

School Counselor

In special education?

Yes No

If yes, describe:

In gifted program?

Yes No

If yes, describe:

Has the child ever been held back in school?

Yes No

If yes, describe:

Which subjects does the child enjoy in school?

Which subjects does the child dislike in school?

Has there been any recent changes in the child's grades?

Yes No

If yes, describe:

Has the child ever been tested psychologically?

Yes No

Feelings about School Work

Please check the descriptions which relate to your child the most:

Anxious

Passive

Enthusiastic

Fearful

Eager

No expression

Bored

Rebellious

Approach to School Work

Performance in School (Parent's Opinions):

Child's Peer Relationships

Select all that apply

Spontaneous

Follower

Leader

Difficulty making friends

Makes friends easilly

Long-time friends

Shares easily

Who handles responsibility for your child in the following areas?

If the child is involved in a vocational program or works a job, please fill in the following:

Current employer

Position

Hours worked

per week

How many previous jobs or placements has the child had?

Usual length of employment

months

Usual reason for leaving

Leisure/Recreational

Describe special areas of interest or hobbies:

e.g. art, books, crafts, physical fitness, sports, outdoor activities, church activities, walking, hunting, cooking, fishing, bowling, school activities, scouts, etc...

Chemical Use History

Does the child/adolescent use or have a problem with alcohol or drugs?

Yes No

If yes, please describe:

Counseling/Prior Treatment History

Information about the child/adolescent (past & present):

Please select if child has past or present history of utilizing services below:

Counseling

Psychiatric

Drug/Alcohol Treatment

Hospitalizations

Psychological Testing

Other

None

If any of the above services used, please provide dates, locations and overall experience of services utilized.

Legal History

Has the child ever been involved in the legal system?

Yes No

If yes, describe:

Is the child currently involved in the legal system?

Yes No

If yes, describe:

Are there any criminal and/or civil cases pending? e.g. custody issues

Yes No

If yes, describe:

By signing below, I hereby acknowledge that the information provided is true to the best of my knowledge. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

This was signed by:

Name

Date

Relationship to Patient (if other than patient)

Currently interested in these services:

Medication Management

Therapy

Medication Management and Therapy

Insurance Policy Holder Information

Carrier

e.g. Blue Cross Blue Shield, Health Alliance, Health Link, Aetna

Policy Holder Name

Policy Holder Phone Number

Policy Holder Date of Birth

Policy Holder Address

City

State

Zip Code

Policy Holder Social Security No.

Relation to Policy Holder

Please Attach Front and Back of Insurance Card

Insurance Card

Add file

Please upload a file

Secondary Insurance

Add file

Please upload a file

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