New Patient Form-Child (Age 2-17)

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. *

Yes- I do have an appointment scheduled

Today's Date * +

Appointment Date * +

Child's Name: *

Date of Birth: * +

Age: *

Street Address: *

City: *

State: *

Zip Code: *

Best number to contact you: *

Best time to contact you? *

Person Completing Form: *

Relationship to Child: *

Child's Physician: *

What are your child's strengths? *

Goals for this appointment/therapy session? *

What is your main concern? *

Child's school:

Grade Level: *

Average grades of child? *

A/B

B/C

C/D

D/F

Have a change in grades occurred? *

YES

NO

Comments from the school that concerned you:

Does child receive special services:

Current concerns/complaints that have brought you to our office: *

What have you tried to do to solve these problems?

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What led you to seek help now?

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What do you expect from the evaluation?

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Has your child been given a diagnosis? *

YES

NO

When and by whom?

Psychiatric/Behavioral Health History:

Please list the names of any psychiatrists, psychologists, or therapists seen in the past (if not local, please list city & state):

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Has any school corporation or other individuals provided any testing for your child? (Please provide details such as dates, who did their testing and what were the findings in regards to diagnosis and recommendations.) Bringing a copy of this testing to the appointment would be most helpful for Midwest Behavioral Health.

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Have there been any In-Patient psychiatric hospitalizations/ Please Specify dates and locations: *

Other areas of concern: *

Medical History:

How would you rate your child's overall health? *

Date of last Physical Exam by Primary Physician: *

Any recent laboratory studies, EEG's, blood test, etc.?

History of Head Injury? *

YES

NO

Loss of Consciousness? *

YES

NO

History of Seizures? *

YES

NO

Please explain any medical hospitalizations and briefly note the reason why:

Please list any surgeries with dates and locations:

Any Medication allergies? *

YES

NO

if yes, what are they?

Please list ALL prescription and non-prescription products they take; include nutritional supplements as well:

Please check all medications below that your child has tried in the past. *

Other Other

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. *

I have read and understand the above statement.

As far as you know, do they use tobacco products of any type? *

YES

NO

Drink alcohol? *

YES

NO

If yes, how often?

Have they ever used marijuana, cocaine, benzodiazepines (Xanax, Klonopin, etc.), pain medication, stimulants (Adderall, Ritalin, etc.) that were NOT prescribed specifically for them? *

YES

NO

Who lives within the home with your child? *

What is the present marital status of this child's parents? *

Married

Separated

Divorced

Other Other

If divorced, who has custody, what are the living arrangements and visitation schedule?

If applicable, list your children with their ages:

What is the level of education for mother: *

Father: *

Are both parents currently employed? *

YES

NO

If so, where and for how long?

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Please list any family members (especially parents and siblings) with psychiatric/behavioral health problems and their diagnoses:

Is your child athletic? *

YES

NO

Do they get along well with their peers & have lots of friends? *

YES

NO

Do they prefer friends who are: *

Same Age

Older

Younger

What are your child's interests, & or leisure activities? *

Are they artistic, creative, or have any other skills or gifts?

Please list any past or current legal issues:

Has your child ever been emotionally/verbally, physically, or sexually abused? *

YES

NO

If yes-Please specify age, length of abuse, relationship to abuser, and legal outcome:

Have they ever witnessed domestic violence of any type? *

YES

NO

Were there any significant problems during the pregnancy? *

YES

NO

N/A

Healthy at birth?

YES

NO

NICU?

YES

NO

Have they walked on time?

YES

NO

Talked on time? *

YES

NO

Any areas NOT covered that you feel are important to bring to our attention?

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 *

was on medication

was not on medication

not sure?

Symptoms *

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

Performance *

	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
48.) Over all school performance	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
49.) Reading	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
50.) Writing	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
51.) Mathematics	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
52.) Relationship with parents	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
53.) Relationship with siblings	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
54.) Relationship with peers	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic
55.) Participation in organized activities (eg, teams)	1 Excellent	2 Above Average	3 Average	4 Somewhat of a Problem	5 Problematic

Comments:

Depression	School issues	Video Games	Runs Away	Steals
Substance Abuse	Anxiety/Stress	Hyperactive	Eating Disorder	Lies
Suicidal Thoughts	Parent/Child Issues	Sexual Trauma	Attention Problems	Refuses School
Homicidal Thought	Physical Abuse	Emotional Abuse	Moodiness	Sets Fires
Aggression	Relationship issues	Legal Issues	Threatens Others	Sleep Issues/Nightmares

Ritalin	Vyvanse	Adderall	Concerta	Daytrana
Focalin	Strattera	Intuniv	Viibryd	Pristiq
Cymbalta	Lexapro	Prozac	Zoloft	Paxil
Effexor	Wellbutrin	Lamictal	Depakote	Abilify
Seroquel	Saphris	Risperdal	Geodon	Latuda
Zyprea	Xanax	Ativan	Klonopin	Have not tried any of these medications