Howardregional.com

1055 N. Curtis Rd. • Boise, ID 83706 • (208) 367-2121 CHILD/ADOLESCENT INTAKE FORM
Patient Information:
Individual Name:
Patient Contacts:
Mother's name:
Contact phone numbers: Name/Relationship: Support Services:
Does this individual receive services from Health and Welfare?
Referral Information:
Presenting Problem:
What concerns you most about this individual? How has this problem affected his/her function? Do you have other concerns you want addressed? Have you recently worried that your child has (please circle items relevant to your child): No DEPRESSION (sad, irritable, hopeless, poor sleep, crying, social withdrawal/isolative behaviors, lack of interest in things, etc.) No MOOD SWINGS (energetic, little sleep, pleasure seeking, racing thoughts, too talkative, inappropriate sexual behaviors, grandiose, etc.) No ANXIETY (worries, restless, scared, poor sleep, obsessive thoughts and/or compulsive behaviors, frequent complaining of headaches and/or stomach aches, frequent school absences, etc.) No BEHAVIORAL PROBLEM (fights, anger, arguing, truancy, destruction of property, fire No ATTENTION/HYPERACTIVITY PROBLEM (difficulty sustaining attention, hyperactive, impulsive, distractibility, not completing tasks) No ABNORMAL EATING BEHAVIORS (too much, too little, fear of weight gain, distorted body No SOCIAL ANXIETY (shy and/or afraid to be around others) No REMEMBERING PAST TRAUMAS (frequent nightmares, intrusive and/or recurrent No AUTISM (social and language impairments, rigidity) No PSYCHOSIS (hearing voices, seeing things, paranoia, delusions) No DISSOCIATION (feeling outside your body or things are not real, etc.) No Has your child ever harmed themselves intentionally? Attempted suicide? Harmed Sleep Patterns:
Does the individual take naps during the day? If Yes, how many hours in a typical day? If yes to any of the concerns listed above, please describe: Past Psychiatric History: Please list any previous psychiatric hospitalizations, residential, or day treatment programs (including any alcohol and drug treatment programs) Please list any current or prior outpatient psychiatrists and therapists your child has seen? Please list this individual's current psychiatric medications. (You may refer to the list of medications on the next page) Please list this individual's current non-psychiatric medications. Please list all the psychiatric medications that have been tried in the past (if greater than 4 medications please attach separate list). (You may refer to the list of medications on the next page). Example: Dexedrine, 5 mg twice daily, 09/98-11/98, good, poor sleep Drug and Alcohol History:
Substance
Date of Last Use
Problems Related to Use
Treatment Required
Is there anything else we should know about any drug history? ®®Tofranil®®®®®®escitalopram®®®®® Restoril® (temazepam) Consider this individual's immediate family and all of their relatives on both sides (parents, brothers, sisters, aunts, uncles, grandparents, and 1st cousins) Review the list below – if any relative has one of these disorders, check the disorder and describe their relation to your child (such as "Maternal Uncle") and their treatment history (if applicable). Maternal is mother's side of the family and Paternal is father's side of the family. Autism/Asperger/Pervasive Developmental Disorder Immunological disorders (lupus, scleroderma, inflammatory bowel disease) Developmental History:
Did your child achieve the following milestones early (E), average (A), or late (L) compared with other
his/her age (please explain if late):
Language (age at first using words, sentences, etc.…)? Fine motor skills (building towers with cubes, drawing circle) Gross motor skills (rolling over, standing, walking)? Has your child experienced any regression of these? How old was this child's biological parents when he/she was conceived? Was this the biological mother's first pregnancy? If no, how many times was she pregnant before this pregnancy? Did the biological mother experience any miscarriages before or after this pregnancy? When was prenatal care first received (in weeks): How much weight did the biological mother gain during this pregnancy?: Did the mother have any ultrasounds or amniocentesis? Please indicate whether any of the following events/problems occurred during this pregnancy. Please include the trimester in which the event occurred, as well as any other important details. Did you take any medications (prescription and over the counter) during this pregnancy? (If yes, please complete the following table.) Did you consume alcohol during this pregnancy? Did you smoke or use tobacco products during this pregnancy? If yes, please describe how much and how often? Did you use any drugs during this pregnancy? If yes, please name drug(s), how much and frequency of use: Labor Information: Type of delivery (c-section, vaginal): Were there any problems with the baby's health right before or immediately after delivery? Were the mother and/or baby separated after birth for more than 24 hours at a time?
Past Medical History:
Primary Care Provider:
Allergies (drug, food, seasonal, environmental etc.)? Has your child ever experienced a head injury, loss of consciousness, or seizure? Does your child have any chronic medical problems? Does your child have a history of any serious injuries or medical hospitalizations? Does your child have chronic pain (frequent headaches, stomachaches, chest pain)? Do you have any concerns related to your child’s balance or ability to walk? _______________________ Has your child had a significant unintentional or unexpected fall in the past year? ___________________ (consider referral to STARS if yes) In the past year, has your child lost or gained weight without meaning to? How much and in what time frame? _______________________________________________________ How many meals a day does your child eat? ________________________________________________ Have you recently worried that your child may have problems with: Endocrine (i.e., diabetes; thyroid dysregulation; excessive hair growth) Has your child ever had an EEG, MRI, CT SCAN, etc? If yes, why was it done and were the results normal? If yes, where were the tests performed and who ordered them? Social History:
Is there any contact with their biological parent(s)? If yes, please list their age at time of move and location: Parents: (Including Step-Mother and Step-Father, if applicable) Name Relationship with Child (quality) Please list the other children in the family and other household members who may also be living in your home: Name
Abuse History:
Has your child ever been the victim of abuse or neglect?
If yes, what was the nature of the abuse? (Please circle all that apply.) Are you struggling with your marital relationship or parenting? Has your child ever been involved with the following and if yes, please explain: What are your child's academic strengths? Has there been a change in your child's performance at school? Has your child received IQ or Academic testing? Does or has your child participated any of the following? Resource (for which classes/how many hours?) Accelerated or Honors programs, explain: Individual Education Plan (IEP), explain: Has your child had problems with any of the following? What are your child's favorite activities? How does your child learn best? Verbal explanations_________ Written informational handouts_______ Other ____________ Does your child have any significant problems that might affect learning? (Such as, trouble seeing or hearing, difficulty in understanding, speaking a different language, other) ____________________________________________________________________________________ ____________________________________________________________________________________ Does your child have quality relationships with other children? Culture:
Do you have a religious preference in the household? Has your child experienced any problems related to race, religion, or culture? TEEN/YOUNG ADULT SECTION
Do you have any concerns regarding your adolescent's friendships? Has your adolescent had a recent change in friendships? Are you concerned that your adolescent is using (or has used) drugs (including over the counter medicines) or alcohol? Are you concerned about your child's sexual activities? Has your adolescent's behavior ever resulted in police, detention, or court involvement? Is there anything else you would like us to know about your child? Mental Status Exam:

Source: http://www.howardregional.com/documents/boise/behavioral_childintake.pdf