Anxiety / OCD Intake
Please fill out the questions below. Our nurse will reach out to you with in 3-5 business days with next steps.
Name of parent completing this form
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First Name
Last Name
Parent's cell phone
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent's Email
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example@example.com
Name of child (patient)
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First Name
Last Name
Child's date of birth
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/
Month
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Day
Year
Date
Primary Care Provider your child usually sees for well visits: (Please note we are only accepting patients of Frederick County Pediatrics)
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Dr. James Lee
Sara Cowan, CPNP
Brendan Koning, CPNP
Alexandra Price, CPNP
What are your concerns regarding your child?
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How long has this been a concern?
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Our current therapist has limited availability for appointments. She is currently offering every other Saturday only. Would this day of the week work for your family?
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The questions below are from the DIAMOND Screener- Parent/Guardian Version
1. My child refuses to speak in some situations
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Yes
No
2. My child gets very anxious or fearful in social situations or when he/she is being observed
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Yes
No
3. My child has had a panic attack, where he/she experienced a lot of fear and physical sensations that came out of the blue
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Yes
No
4. My child feels very fearful or anxious in situations where it's difficult to escape quickly or get help (for example, using public transportation, being in open or enclosed spaces, standing in line or being in a crowded place or being alone away from home)
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Yes
No
5. My child feels excessively anxious or worried about many things, a lot of the time (for example, worry about finances, responsibilities at work/school, his/her health or the health of others)
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Yes
No
6. There are certain objects, situations, or activities that my child is very afraid of (for example, like animals, insects, blood, needles, heights, storms, flying, choking, vomiting, or enclosed spaces)
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Yes
No
7. My child feels very afraid to be away from a certain person or people
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Yes
No
8. My child has had a period of four days or more when his/her mood was so good or elevated, like he/she was on top of the world, that it caused problems for him/her, or people thought he/she wasn't his/her usual self
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Yes
No
9. My child has been feeling down, blue, or depressed frequently over the past year
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Yes
No
10. My child has had a time when he/she felt very sad, blue, down, or depressed, or lost interest or pleasure in his/her usual activities, for two weeks or more
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Yes
No
11. My child has really bad temper outbursts
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Yes
No
12. (If applicable) My child gets really depressed, irritable, anxious, or has mood swings in the week prior to menstruation (her period)
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Yes
No
N/A
13. My child has frequent thoughts, urges, or images that he/she doesn’t want to have (for example, thoughts about being contaminated even though he/she may not be, or that he/she may hurt someone else even though he/she doesn’t want to)
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Yes
No
14. My child does repetitive behaviors (for example, hand washing or cleaning, ordering or arranging, checking things, or repeating behaviors over and over), or repeatedly does things in his/her mind (for example, counting, saying certain words or phrases) in order to feel better or to prevent something bad from happening
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Yes
No
15. My child spends a lot of time worrying about his/her physical appearance
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Yes
No
16. It’s hard for my child to throw things away
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Yes
No
17. My child frequently pulls out hair from his/her scalp or body
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Yes
No
18. My child frequently picks at his/her skin
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Yes
No
19. My child has a physical health problem that makes him/her very worried or anxious, or requires him/her to do a lot to diagnose or monitor it
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Yes
No
20. My child often worries that he/she has a serious medical illness or injury, or that he/she is going to develop a serious medical illness or injury
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Yes
No
21. My child is distressed about a really bad event (like seeing something that was life-threatening or caused someone to die, being seriously injured or seeing someone be seriously injured, or being sexually assaulted or molested) that he/she experienced or witnessed
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Yes
No
22. My child is having a hard time dealing with a stressful or unpleasant experience, or a major change in his/her life
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Yes
No
23. My child avoids eating food because he/she thinks he/she is overweight
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Yes
No
24. My child often has eating "binges," in which he/she eats more than most people would eat, and it feels like his/her eating is out of control
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Yes
No
25. My child eats very little, has difficulty eating enough, or avoids certain foods
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Yes
No
26. My child has had more than one alcoholic drink, more than once
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Yes
No
27. My child has used drugs (including cannabis, even if prescribed), or he/she has used prescription medications other than how they were prescribed
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Yes
No
28. My child has difficulty paying attention or concentrating when he/she needs to
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Yes
No
29. It often seems that my child has difficulty sitting still or waiting for things
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Yes
No
30. My child has a lot of sudden movements (tics) that are hard to control, or makes sounds that are hard to control
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Yes
No
31. My child often has aggressive outbursts
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Yes
No
32. My child feels angry or cranky, and gets into arguments a lot
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Yes
No
33. My child has broken the law or done things that could have hurt other people in the past year
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Yes
No
34. My child has had very strong beliefs in something that other people thought were strange, such as any of the following: a. That people were conspiring against him/her, spying on him/her, or harassing him/her b. That a governmental or religious organization was following him/her or harassing him/her c. That someone my child didn’t know, such as a celebrity, was in love with him/her d. That he/she had special talents or powers, or that he/she was famous e. That there was something very strange going on with his/her body f. That someone had removed thoughts from his/her mind, placed thoughts in his/her mind, or read his/her mind g. That someone or something was controlling his/her movements and actions h. That someone was sending him/her special messages through the TV, radio, or books i. That he/she did not exist, that the world did not exist, or that the world was ending j. That a partner was being unfaithful to him/her k. That he/she was responsible for a disaster or serious crime and needed to be punished
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Yes
No
35. My child has had sensory experiences that others could not understand, such as: a. Hearing sounds that others couldn’t hear, such as voices or music b. Seeing things that others couldn’t see, such as colors, animals, people, or spirits c. Having unusual sensations in his/her body, such as a feeling of electric shocks or bugs on him/her d. Smelling odors that others could not smell, such as vomit, feces, or something rotting
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Yes
No
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