HM Child-Adolescent Patient Progress Report

Harmonious Mind (Psychiatric and Counseling Services)

5189 W. Woodmill Dr., St.30, Wilmington, DE 19808. On the Web: www.HarmoniousMind.com

Tel: 302.633.6001 Fax: 302.295.6289 SMS/Text: 302.565.4818 Email: Support@HarmoniousMind.com

Today's Date

Patient's Full Name

Date of Birth

Parent/Guardian's Full Name

Insurance

Pharmacy Name and Tel.

Have you had any health related changed since your last visit?

Yes No

Are you or a family member involved in a court case?

Yes

If yes, provide details.

Provide details of open/active court case or legal issues or any kind.

Describe your sleep. Any scary dreams?

Any Changes to your weight?

Yes No

Describe your appetite.

Describe your/patient's energy levels? List Daily activities.

Describe your/patient's mood.

Have you/patient experienced crying or withdrawal from others?

Have you/patient had thoughts of harming self?

Yes No

If yes, provide details.

Do you have any Plans of harming yourself or others?

How do you cope with thoughts of hurting or harming yourself?

Has the patient been agressive?

Has the patient has thoughts of running away?

Any scary or angry voices or visions

Any evidence of agitation?

Have you had trouble trusting?

Yes No

If Yes, provide details.

Have you had feelings of agitation?

Yes No

If yes, provide details.

Have you had feelings of paranoia?

Yes No

If yes, provide details

Any panic attacks or anxiety ?

Any fear of being out in car, in store, or in presence of others, or in crowds?

Any urges to steal, gamble, spend, fire-set?

Any memory problems?

Any confusion spells?

yes no

Any Medication Changes?

Yes No

If yes, provide details.

Emergency Visit to ER or Doctor?

Yes No

If yes, Provide details.

Any New Stresses - Changes in school, work, home, family, relationships, peer, etc.

Overall progress or worsening of symptoms

Any side-effects from psychiatric medications?

Are you using alcohol or any illicit drugs?

What have you been working with your therapist on?

Describe any other General Symptoms - Aches, pain, muscle stiffness, etc. - Eyes - ENT - Cardiovascular – Palpitations, etc - Respiratory - Gastrointestinal - Genitourinary - Muscular - Integumentry - Neurological - Endocrine - Hemotologic - Allergies

Are you using any alcohol or illicit drugs?

Questions you may like to ask the doctor about medicines? Other concerns you may have?

Enter Full Name of Patient, as Signature

Date Signed

Your information will be encrypted.