New Patient Evaluation

Emergency Assistance

If this is an emergency, call:

Crisis Line: (XXX) XXX-XXXX
911

Patient Information

Child first name

Child last name

Date of birth

Gender

Primary Care Physician

PCP Practice

Parent or Guardian Information

First name

Last name

Relationship to Child

Cell phone number

Email address

Street Address

City

State

Zip Code

Reason For Visit

In a few words describe the reason for your visit

Developmental and Behavioral Concerns

Describe any concerns you have about your child's:

Large and Small Motor Skills:

Language/Communication Skills:

Learning or School Concerns:

Hyperactivity:

Attention:

Social Skills/ Friendships/ Play Skills:

Conduct/Behavior Problems:

Depression/Sadness:

Anxiety/Worries/Fears:

Repetitive Behaviors/Compulsions/ Unusual Habits:

Sensory Problems:

Adaptability/ Rigid/ Inflexible Behaviors:

Sleep:

Pregnancy and Birth History

Birth Weight

Full Term or Pre Term?

Method of Delivery

Describe and complications of the pregnancy or delivery

Medical History

Chronic Medical Problems

Current Medications:

Previous Medications:

Allergies to any Medications:

Developmental and Behavioral Health History

Developmental Milestones:

Walking:

First word:

Combined words (i.e. "My Ball"):

Has your child had previous psychological/ developmental/ psychiatric evaluations? If so, please list names and approximate dates

Educational History

Name of preschool/ daycare /school. If in school, what grade? Describe any support services or extra help your child receives in school.Note if your child has an IEP or 504 plan

Social History

Please briefly describe your child's living arrangements and home life

Has the child experienced or witnessed abuse or domestic violence?

Yes No

Has the child experienced the separation or divorce of parents?

Yes No

Describe any other significant life changes or stressful events that the child has recently experienced.

Is there anything else regarding the child's personal history that we should be aware of?

Family History

Please describe any family history of ADHD, Anxiety, Depression, Autism Spectrum Disorders. Learning Disabilities, Genetic Disorders, or Heart Problems

Please upload any school accommodations, previous evals or anything relevant to concerns

Files

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