PARTNERS IN PEDIATRIC CARE. Intake and History for Mental Health Referral
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1 PARTNERS IN PEDIATRIC CARE Intake and History for Mental Health Referral This form is designed to give you an opportunity to provide us with background information that will help us help you. Please read the questions carefully and answer them as thoroughly as possible. Completion of this form is the first step in your child s evaluation and treatment. By answering these questions in advance, we will be able to spend more time during the initial interview discussing the issues that are most important to you. This information will be kept in complete confidence. Thank you for taking the time to complete this document. Date of Intake Identifying Information Child/Teen Name Date of Birth Sex: Male Female Father s Name Age Mother s Name Age Siblings Age Living at home: Yes No Yes No Yes No Yes No Anyone else living in the home? Reasons for Referral Who referred you to our practice? Briefly describe the reasons you are scheduling this appointment.
2 How long has the problem been occurring? Please circle all that apply for your child and note age of occurrence. Age Age Head injury Bed-wetting/Soiling Arthritis Panic Concussion Tantrums Scoliosis Tobacco Abuse Loss of Appetite Cancer Weight Gain or Loss Suicidal Ideas Eating Disorder GI Problems Frequent Headaches Suicidal Attempt Seizures Difficulty w/daily routine Fainting/Dizziness Aggressive Behavior Family Stress Bowel Problems Frequent Crying Bladder Problems PTSD Diabetes Hearing Problems Thyroid Problems Vision Problems Gynecological Problems Sleep Problems Fire Setting High Blood Pressure Abuse Chest Pain ADHD Asthma Anger Shortness of Breath Anxiety Hives/Rashes Autism/ Asperger s/mr Sleep Disorder Behavior Problems Nightmares Bipolar Disorder Night Sweats Chronic Pain Self Injury Depression Divorce/Separation Grief Schizophrenia School Issues Alcohol Abuse Substance Abuse Other Please use this area to comment on any of the items listed above.
3 History of Treatment Please list the names of any doctors or professionals who have evaluated or treated your child. If your child has ever had a medical or psychiatric hospitalization please list the following: Hospital Name Dates of Treatment Reason for Admission Please list ALL medications your child has taken or is taking, including dosage and times. Please list any side effects or adverse reactions your child has had to a medication. Family History Please list any events you believe are significant in your child s life such as an auto accident, illness or death of a family member. Please list any family members treated for mental health/ substance abuse issues and the diagnosis.
4 Developmental History Was the pregnancy with this child full term? Yes No If not full term, how long was the pregnancy? Please list any medications the mother took during the pregnancy. During the pregnancy did the mother use Street Drugs: Yes No Alcohol: Yes No The birth was: Natural Caesarean Labor Induced Birth Weight Breast Fed Bottle Fed Please list any complications during or following the birth. Developmental Milestones (please note ages achieved) Crawled Walked Spoke First Words Spoke in Sentences Weaned Toilet Trained Educational History Elementary School (name) (current grade) Middle School High School College If the child has repeated any grades, which grade? Is the child receiving any Special Education Services Yes (please explain) No
5 Social Relationships Does your child make friends easily? Yes No Please explain any concerns with social relationships. Our Goal Our goal is to offer personalized care with you as our partner. Please list any questions or concerns you may have that were not addressed above. Thank you for taking the time to complete this form. We look forward to meeting you and your child.
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