Child and Adolescent New Patient Form
I understand that I am only to complete this paperwork IF I have a scheduled appointment. If I do not have an appointment I understand that I am to complete the Self-Referral Intake Form first. *

Average grades of child? *
Have a change in grades occurred? *
Does child receive special services:
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Has your child been given a diagnosis? *

Psychiatric/Behavioral Health History:
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Other areas of concern: *
Medical History:
How would you rate your child's overall health? *
History of Head Injury? *
Loss of Consciousness? *
History of Seizures? *
Any Medication allergies? *
Please check all medications below that your child has tried in the past. *
Please bring a list of medications covered by your insurance to your appointment.
I understand that if I fail to provide a copy of the approved medications from my insurance, the doctor may choose a medication that is not covered by my insurance plan. Midwest Behavioral Health will not be responsible for obtaining prior authorization for your medication. *
As far as you know, do they use tobacco products of any type? *
Drink alcohol? *
Have they ever used marijuana, cocaine, benzodiazepines (Xanax, Klonopin, etc.), pain medication, stimulants (Adderall, Ritalin, etc.) that were NOT prescribed specifically for them? *
What is the present marital status of this child's parents? *
Are both parents currently employed? *
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Is your child athletic? *
Do they get along well with their peers & have lots of friends? *
Do they prefer friends who are: *
Has your child ever been emotionally/verbally, physically, or sexually abused? *
Have they ever witnessed domestic violence of any type? *
Were there any significant problems during the pregnancy? *
Healthy at birth?
Have they walked on time?
Talked on time? *

NICHQ Vanderbilt Assessment Scale- Parent Informant
Directions:  Each rating should be considered in the context of what is appropriate for the age of your child.  When completing this form, please think about your child's behaviors in the past 6 months.
Is this evaluation based on a time when the child *
Symptoms *
 0 Never1 Occasionally2 Often3 Very Often
1.) Does not pay attention to details or makes careless mistakes
2.) Has difficult keeping attention to what needs to be done
3.) Does not seem to listen when spoken to directly
4.) Does not follow through when given directions and fails to finish activities (not due to refusal or failure to understand)
5.) Has difficulty organizing tasks and activities
6.) Avoids, dislikes, or does not want to start tasks that require ongoing mental effort
7.) Loses thing necessary for tasks or activities (toys, assignments, pencils, or books)
8.) Is easily distracted by noises or other stimuli
9.) Is forgetful in daily activities
10.) Fidgets with hands or feet or squirms in seat
11.) Leaves seat when remaining seated is expected
12.) Runs about or climbs too much when remaining seated is expected
13.) Has difficulty playing or beginning quiet play activities
14.) Is "on the go" or often acts as if "driven by a motor"
15.) Talks too much
16.)Blurts out answers before questions have been completed
17.) Has difficulty waiting his or her turn
18.) Interrupts or intrudes in on others' conversations and/ or activities
19.) Argues with adults
20.) Loses temper
21.) Actively defies or refuses to go along with adults' requests or rules
22.) Deliberately annoys people
23.) Blames others for his or her mistakes or misbehaviors
24.) Is touchy or easily annoyed by others
25.) Is angry or resentful
26.) Is spiteful and wants to get even
27.) Bullies, threatens, or intimidates others
28.) Starts physical fights
29.) Lies to get out of trouble or to avoid obligations (ie, "cons" others)
30.) Is truant from school (skips school) without permission
31.) Is physically cruel to people
32.) Has stolen things that have value
33.) Deliberately destroys others' property
34.) Has used a weapon that can cause serious harm (bat, knife, brick, gun)
35.) Is physically cruel to animals
36.) Has deliberately set fires to cause damage
37.) Has broken into someone else's home, business, or car
38.) Has stayed out at night without permission
39.) Has run away from home overnight
40.) Has forced someone into sexual activity
41.) Is fearful, anxious, or worried
42.) Is afraid to try new things for fear of making mistakes
43.) Feels worthless or inferior
44.) Blames self for problems, feels guilty
45.) Feels lonely, unwanted, or unloved; complains that "no one loves him or her"
46.) Is sad, unhappy, or depressed
47.) Is self-conscious or easily embarrassed
Performance *
 1 Excellent2 Above Average3 Average4 Somewhat of a Problem5 Problematic
48.) Over all school performance
49.) Reading
50.) Writing
51.) Mathematics
52.) Relationship with parents
53.) Relationship with siblings
54.) Relationship with peers
55.) Participation in organized activities (eg, teams)
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