Behavioral Health Intake Form
Date
*
-
Month
-
Day
Year
Date
Parent's Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Primary Care Provider (we are only able to accept patients of Frederick County Pediatrics at this time)
*
Your child's medical insurance (name of insurance company)
*
Is this a Maryland Medicaid plan? (If yes, which one?)
Current Concerns
*
Depressed / seems down
Difficulty at school or daycare
Excessive worry / anxiety
Not getting along with others
Anger / Aggression
Increase in risky behavior
Fatigue
Fears / Phobias
Loss of interest
Concentration / focusing concerns
Excessive guilt
Increased irritability
Tantrums
Family Separation / Divorce
Sleep Concerns
Strained Family Relationship
Other
Anything additional to mention?
Submit
Should be Empty: