Psychiatry Patient Information Form Ages 17 and Under

(To be completed by patient’s parent/guardian)

Date*

Name*

First Last

Preferred Name:

Date of Birth*

Age:*

Parent/Guardian Contact Name(#1):*

Parent/Guardian Contact Phone (#1) :*

Parent/Guardian Contact Name Email (#1)*

Parent/Guardian Contact Name(#2):

Parent/Guardian Contact Phone (#2) :

Parent/Guardian Contact Name Email (#2)

Who referred your child?*

What was their concern?

What is your primary concern(s)?

If applicable, what is the school’s primary concern(s)?

When did you first develop or become aware of these concerns?

FAMILY INFORMATION

Who has legal custody or guardianship of the child:*

Parent/Caregiver/Guardian 1:

Name

First Last

Relationship to child:

Phone

Date of Birth

Age:

Address (if different from the child’s)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Highest level of education:

Occupation:

Parent/Caregiver/Guardian 2:

Name

First Last

Relationship to child:

Phone

Date of Birth

Age:

Address (if different from the child’s)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Highest level of education:

Occupation:

Please identify marital status including dates of all marriages/divorces/separations/remarriages for the child’s parents:

Please provide the following information regarding the child’s full siblings, half siblings, step-siblings, or children living in the home: 1. Name 2. Age 3. Grade/Occupation 4. Relationship to Patient 5. Where do they live? (Mom’s, Dad’s, etc.)

List any other adults or family members who are currently living in the home their relationship the child:

List dates of any moves and for what reasons.

How long has the child lived at their present address?

DEVELOPMENTAL INFORMATION

Length of Pregnancy

Birth Weight

Planned or unplanned pregnancy

Any complications during the pregnancy?

Any tobacco, alcohol, or substance use during the pregnancy?

Type of Delivery (C-section, Vaginal):

Any complications during the delivery or right after birth?

If child was adopted, from where?

At what age was child adopted?

Age of parent(s) at time of birth or adoption:

How old was your child when they first began to: Talk

How old was your child when they first began to: Walk

When were they full toilet trained

Any current concerns regarding your child’s physical or social development?

EDUCATION HISTORY

What school is your child currently attending school?

What grade are they in?

Do they have any academic accommodations (such as an IEP or 504 plan, Special Education, etc.)?

If so, when did these first begin?

Any concerns regarding school attendance? Learning?

Has your child every been held back or repeated a grade?

SOCIAL INFORMATION

What does your child like to do for fun?

Are they involved in any extra-curricular activities?

Is your child currently dating or in a relationship?

Is your child currently employed?

Does your child have any legal issues?

Please note any significant losses or events that have impacted your child’s life and when they occurred:

History of Trauma and/or Abuse: (if checked, please explain)

Describe: Life threatening traumatic event of self

Describe: Life threatening event of another

Describe: Domestic Abuse (either witnessed or received)

Describe: Physical Abuse

Describe: Emotional/Verbal Abuse

Describe: Sexual Abuse

Describe: Abandonment/Neglect

Describe: Other:

GENERAL MEDICAL INFORMATION AND HISTORY

Primary Care Clinic/Location:

Primary Care Physician’s (PCP) Name:

Other medical providers your child sees (Names, locations, & specialties)

Please list any allergies to medications:

Current Physical Health Conditions:

Previous Medical Hospitalizations (if so, when):

Previous Surgeries (if so, when):

Does your child have any history of significant head injury, concussion, or seizure (if so, when)?

Substance Use History

(Fill only those fields that apply to you)

Alcohol: Current:

Yes
No

Alcohol: Age of First Use

Alcohol: Age/Date Last Used

Alcohol: Specific Type Used

Benzodiazepines (Xanax, Klonopin and other ... pams) Current:

Yes
No

Benzodiazepines (Xanax, Klonopin and other ... pams) Age of First Use

Benzodiazepines (Xanax, Klonopin and other ... pams) Age/Date Last Used

Benzodiazepines (Xanax, Klonopin and other ... pams) Specific Type Used

Meth, Cocaine, Crack Current:

Yes
No

Meth, Cocaine, Crack: Age of First Use

Meth, Cocaine, Crack Age/Date Last Used

Meth, Cocaine, Crack Specific Type Used

Hallucinogens Current:

Yes
No

Hallucinogens Age of First Use

Hallucinogens Age/Date Last Used

Hallucinogens Specific Type Used

Narcotic Pain Pills or Heroin Current:

Yes
No

Narcotic Pain Pills or Heroin Age of First Use

Narcotic Pain Pills or Heroin Age/Date Last Used

Narcotic Pain Pills or Heroin: Specific Type Used

Inhalants: Current:

Yes
No

Inhalants: Age of First Use

Inhalants:Age/Date Last Used

Inhalants: Specific Type Used

Cannabis/Marijuana: Current:

Yes
No

Cannabis/Marijuana: Age of First Use

Cannabis/Marijuana: Age/Date Last Used

Cannabis/Marijuana: Specific Type Used

Nicotine/E-Cigs: Current:

Yes
No

Nicotine/E-Cigs: Age of First Use

Nicotine/E-Cigs: Age/Date Last Used

Nicotine/E-Cigs: Specific Type Used

OTC Diet: Current:

Yes
No

OTC Diet: Age of First Use

OTC Diet: Age/Date Last Used

OTC Diet: Specific Type Used

Other/Synthetic: Current:

Yes
No

Other/Synthetic: Age of First Use

Other/Synthetic: Age/Date Last Used

Other/Synthetic: Specific Type Used

Natural Supplements: Current:

Yes
No

Natural Supplements: Age of First Use

Natural Supplements: Age/Date Last Used

Natural Supplements: Specific Type Used

Caffeine: Current:

Yes
No

Caffeine: Age of First Use

Caffeine: Age/Date Last Used

Caffeine: Specific Type Used

Please describe any previous chemical dependency treatment:

PSYCHIATRIC HISTORY

Past and Current Mental Health Diagnoses:

Past and Current Mental Health Services (include date(s) and program name):

Past Psychiatric Providers/Physicians:

Past Hospitalizations for Mental Health (include date, location, reason):

Past Psychiatric Medications (Please include medication name, dose, side effects, effectiveness, and dates taken):

Current Medications (Prescribed psychiatric & non-psychiatric, over the counter, and supplements):

Who prescribes your current psychiatric medications:

FAMILY MEDICAL AND PSYCHIATRIC HISTORY

Please check which, if any, of the following conditions/problems apply to your child’s blood relatives. If other significant mental health problems are present among blood relatives, please list those in the space provided below.

Anxiety Disorders