Family Center By The Falls Parent Questionnaire
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- Kenneth Harrison
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1 Child s Name: Preferred First Name: Family Center By The Falls Today s Date: Age: Grade: Names of Parents/Guardians: Name of School: Name of Pediatrician: Who referred you to us? Has your child been seen by a different counselor or psychiatrist in the last 90 days? Yes No If yes, who? What is your main concern about your child at this time? How does this concern affect your child in terms of: 1. General Behavior: 2. Emotional Functioning: 3. Relationships: 4. Physiological Functioning (i.e. stomach aches, etc.) 5. Cognitive (thinking) Functioning: 1
2 What made you decide to seek treatment for your child now? What are you hoping to gain? What additional concerns do you have in addition to the main concern? What are your child s assets (strengths, talents, skills, etc.): Current Observations of your child Please check yes or no Yes No Please check yes or no Yes No Inattention Easily Distracted/Bored Messy, disorganized Forgetful Impulsive Accident Prone Impatient Risk-taking Lazy unmotivated Trouble completing tasks Needs constant reminders Fidgety or restless Hyperactive Panic Attacks Social anxiety Performance anxiety Obsessive Thoughts Compulsive Behaviors Changes in sleep Trouble falling asleep Trouble staying asleep Waking too early Changes in appetite Weight loss/gain Change in energy Losing interest in things Cyclical changes in mood Change in memory/concentration in speech Feelings of hopelessness in sleep Frequent anger episodes in irritability Difficulty with change/transition in distractibility Difficulty reading social cues in impulsivity Rigid, inflexible thinking in thinking in elevated mood in grandiosity Mood changes describe Thoughts of suicide describe 2
3 Prior suicide attempts describe Mood Swings if yes, how long do they last Hallucinations describe Paranoid thoughts describe Odd/inappropriate behavior describe Over the last month what percentage of time has your child been sad/unhappy anxious/worried irritable/angry Has your child seen a counselor or psychiatrist before? If yes, who, when and how did your child respond to treatment? Name of Counselor, Psychologist, Psychiatrist When seen and for how long? How did it help Has your child ever had to leave home to be treated in a psychiatric hospital, residential treatment center, drug rehab, therapeutic school, foster care, etc. or received intensive in-home treatment, MST, partial hospitalization, or Intensive Outpatient services? Name of Facility and Primary Clinician When seen and for what purpose Length and outcome of treatment Family Psychiatric History Have any of your child s blood relatives experienced symptoms similar to your child? What do they have in common? 3
4 Please list any blood relatives who have been treated for any emotional or behavioral issues, including issues with mood, anxiety, ADHD, postpartum depression, etc. If they received medication please state type and any significant benefits or side effects. Name of Related Person How they are related to child Diagnosis How they were treated (medicine, counseling) Response to treatment? Legal Involvement and Substance Abuse History Has your child had any incidents that did (or should have) involved the police? If yes, please describe? Has your child had any court involvement? If yes, name or court and charges: Is your child currently on probation? If yes, please describe why Do you have any reason to believe your child has used the following substance? Alcohol: Age first used: Current use (amount and frequency) Marijuana: Age first used: Current use (amount and frequency) Tobacco: Age first used: Current use (amount and frequency) Other drugs (cocaine, inhalants, stimulants, etc.): Please specify type, amount, and frequency: 4
5 What consequences has your child experienced from substance abuse? Has your child ever had substance abuse assessment or treatment? If yes, please describe where, when, and result? Is there a family history of substance abuse? If yes, please describe who, relationship to child, and substance: Early Development Was your child s conception planned or a surprise? Were there any complications during pregnancy? If yes, please describe: Did mom smoke while pregnant? Yes No Drink Alcohol? Yes No Take Medication Yes No Length of pregnancy (weeks) Type of Delivery: Vaginal or C-section (please state why) Were there any complications that delayed taking your child home? What type of baby was he/she (fussy, colicky, sweet, etc.)? Did your child have any developmental delays (crawling, standing, walking, language)? 5
6 How old was your child when they were toilet trained? Were there difficulties with bedwetting, soiling, or daytime wetting? When did your child sleep first sleep through the night? Who has taken care of your child? Have there been any major disruptions to care or inconsistency in caretaking? Has your child ever been a victim of emotional, sexual, or physical abuse? If yes, please describe. How has/does your child respond to changes in their routine? School What was his/her adjustment to school like? How are his/her mornings before school? How are his/her afternoons after school? How does he/she get along with classmates? Teachers? Has your child ever been suspended, expelled or received detention? If yes, please describe: How is your child s attendance? What is your child s academic performance like? Have there been changes in the past year? 6
7 Are there factors that compromise his/her academic functioning? Was your child every held back? If yes, what grade and why? Has your child been identified as having a learning disability? If yes, by whom and what type of disability? Is your child in any support classes or special education? If yes, describe? Has your child had a multi-factored evaluation? If yes, when (please bring a copy) Does your child have an IEP or 504 plan? Yes No If yes, please bring a copy Does your child s school have a good idea about how to meet your child s needs? Please describe? Is homework completion a problem? Yes No If so how often? Does your child forget to: Turn in work? Yes No If so how often? Write down assignments? Yes No Bring books home for homework? Yes NO Does your child: Make careless mistakes? Yes No Procrastinate on work? Yes No Need lots of supervision to do work? Yes No Take too long on work? Yes NO Does your child have any particular career goals or other future goals? 7
8 Please bring (if applicable) copies of your child s report cards, multi-factored evaluations/etr, IEP, 504 Plan, cognitive testing (Iowa Test, SCOGAT, Stanford Tests, Entrance Exams, etc.) to your child s initial appointment. Peers What are your child s favorite activities and interests? Is your child involved in any sports, clubs, or other extracurricular activities? What are your child s friends like? How long do your child s friendships last? Is it hard for your child to make/keep friends? If yes, describe why: Has your child been involved in dating relationships? Please describe: Is your child sexually active? Yes No Don t Know Does your child have any concerns about: Sexual Orientation: Yes No Gender Identity: Yes No Medical History Complete the italics if patient is female Last menstrual cycle: Using birth control? Yes No Premenstrual mood changes: How would you describe your child s eating patterns? Any changes in appetite? Yes No Weight changes? Yes No Energy Level changes? Yes No 8
9 Does your child have any medical conditions at this time? If yes, please describe and tell how it impacts your child psychologically? Has your child ever been hospitalized? If yes, describe when and why: Has your child had surgery? If yes, describe when and why: Does your child have a preoccupation with fire, matches? Yes No Does your child have a history of Animal cruelty? Yes No Is there a family history of: Structural heart disease (explain): Sudden death before age 50 (explain): Check all that apply: Heart murmur Arrhythmia Structural heart disease Hypertension Tachycardia Chest pain Seizures/Epilepsy Vocal or motor tics Head injury Headaches Tremor Genetic Abnormalities Nausea Vomiting Abdominal pain Anorexia Diabetes Thyroid problems Skin Asthma Allergies Infections Urinary problems Medication Allergies? Please list: Please list medications (not for behavioral/mental health issues) your child takes (dose, times administered) 9
10 Please list over the counter medications, supplements or natural remedies your child takes (does, times) Please list every medication your child is taking or has taken for behavioral/mental health issues, in order, from first to most recent: Medication 1. Dose and time taken Doctor who prescribed Why was it prescribed? Dates taken What did it do? Any additional comments about medication: If your child has never been treated with medication, what fears or concerns would you (or other family members have) if one of our physicians recommended medication? 10
11 Family Relationships and Activities Parents: Married Separated Divorced Name, Age, Occupation Name, Age, Occupation If divorced, what are the custody arrangements: Step-parents if applicable: Step-mom Step-dad Who else lives in the home (other relatives, friends, siblings)? Name, Age, Relationship Name, Age, Relationship Name, Age, Relationship Name, Age, Relationship Name, Age, Relationship What is the relationship like between parents or major caregivers? Has your child ever witnessed domestic violence? If yes, describe: What is your child s relationship like with each parent or caregiver? How do you discipline your child? Is it working? Do the parents agree on discipline and have the same style of parenting? 11
12 How do you promote good behavior? Family Center By The Falls What is the household climate like? Conflictual? Warm? Permissive? How is your child s behavior with each sibling? How does your child s family relationships differ from his/her relationships with others? Please describe your family activities (ie. Travel, board games, etc.) Is your family involved in a church or a place of worship? If yes, where and what is your child s involvement? How does your faith impact your child and how you live your life? What are your family connections in terms of support or significant others in your child s life? Is there anything else about your family that is important for us to know? 12
13 Is there any other important information you would like for us to know about your child or your family? Name of Person Completing Form Relationship to Child 13
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Co Occurring Disorders and the on Children: Effectively Working with Families Affected by Substance Abuse and Mental Illness Definition (Co-Occurring also called Dual Dx) A professional diagnosis of addictive/substance
Delirium. The signs of delirium are managed by treating the underlying cause of the medical condition causing the delirium.
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Ranch Ehrlo Society. referral information. Does this referral meet the TFCP criteria? Child s Name:
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What You Need to Know About Behavioral Health Care Services
Member Messenger 2016 This Issue: Page 1-2 Annual Behavior Health Quality Management Guide Page 3 Member Satisfaction Survey Page 4 Achieve Solutions Self Help Screening Tools Available Page 5-6 Behavioral
JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557
FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
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Advanced Rehab Solutions 609 Morris Avenue Springfield, NJ 07081
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LOW T NATION TESTOSTERONE INTAKE FORM NAME: DATE: ADDRESS: CITY: STATE: ZIP: CELL #: HOME #: SOC SECURITY #: DATE OF BIRTH:
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NEW PATIENT REGISTRATION
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Describe your current employment, including duties, hours, rate of pay and benefits?
CUSTODY INTAKE Name Address Home phone Business phone Cell phone(s) fax e-mail(s) Social Security # other contacts length of marriage (present; and priors) Describe your educational background Describe
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
Other Children: (not in home) Name Age Relationship Job/School Mental Health History Relationship with Child (positive, conflicted, etc.
Psychological and Life Skills Associates, PC 13885 Hedgewood Drive, Suite 245, Woodbridge, VA 22193 601 Jefferson Davis Hwy, Suite 101, Fredericksburg, VA 22401 (703) 490-0336 CHILDREN/ADOLESCENT INTAKE
Methamphetamine. Like heroin, meth is a drug that is illegal in some areas of the world. Meth is a highly addictive drug.
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