New Patient Paperwork- Georgia Psychiatry and Sleep

Patient's Full Name*

First NameMiddle NameLast Name
Preferred Name

Are you filling out this paperwork on behalf of someone under 18?*

NoYes

Birth Date*

MonthDayYear
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender*

MaleFemaleNon-BinaryTransgender MTFTransgender FTM
Preferred Pronouns*

She/Her/HersHe/Him/HisThey/Their/TheirsOther

Release of Information (ROI)- Please list below individuals (family, spouse, friend) with whom your provider can discuss your care or release your psychiatric medical records. If you do not want anyone to discuss your medical records, check "Do Not Release Medical Records" in the last column.*

	Name	Relationship	Phone Number	Do Not Release Medical Records
ROI Person #1
ROI Person #2

Preferred Pharmacy Name*
Provide pharmacy name
Preferred Pharmacy Address*
Provide pharmacy address

Pictures of the front and back of your insurance card and driver's license are required PRIOR to scheduling an appointment.
Insurance Company *
Insurance Member ID Number*
Attach a picture of the FRONT of your insurance card.

Cancelof
Attach a picture of the BACK of your insurance card.

Cancelof
Attach a picture of the FRONT of your Driver's License/Government-Issued ID.

Cancelof

What service are you looking to schedule?

Psychiatric Medication Evaluation (where medication can be adjusted & prescribed)Talk Therapy (Where medication cannot be prescribed)1x Psychiatric Evaluation for Bariatric Surgery1x Psychiatric Evaluation for Spinal Cord StimulatorHospital DischargeOther
What service are you looking to schedule?*

Psychiatric Medication Evaluation (where medication can be adjusted & prescribed)Talk Therapy (where medication cannot be prescribed)1x Psychiatric Evaluation for Bariatric Surgery1x Psychiatric Evaluation for Spinal Cord StimulatorHospital DischargeOther
We are NOT able to complete any paperwork/evaluation for court-ordered treatment or short/long term disability cases.*

I acknowledge
Reason for appointment?*
What symptoms are you currently experiencing?*

Sleep DifficultyAnxietyStressBipolar symptomsDepressionWithdrawal from Substance AbusePTSDADHDPanic AttacksSchizophrenia
Have you ever seen a psychiatrist or counselor in the past?*

YesNo
If yes, please provide the name of psychiatrist, dates seen, treatment reason, and reason for seeking care elsewhere*
Name of Psychiatrist, Dates Seen, Treatment Reason, Reason for Seeking Care Elsewhere. Type N/A if not applicable.
How did you find out about Georgia Psychiatry and Sleep?*

Provider referred meInternet searchFriend/RelativeInsurance ListingOther
Have you been a patient in a psychiatric hospital or in a rehab program within the past year for a drug/alcohol or behavioral problem?*

YesNo
If yes, please give name of facility, location, dates seen, type of program, and treatment reason.*
Type N/A if not applicable

Office Policies*

	I Acknowledge
There is a new patient no-show fee of $100. This will be required to be paid before our staff are able to reschedule an initial appointment. The credit card on file will be charged automatically.
We require at least 48 hour notice (business days) for any new patient appointment cancellations. Failure to do so will result in a cancellation fee of $100 that will be required to be paid before the appointment can be rescheduled. The credit card on file will be charged automatically.
There is an existing patient same-day cancellation fee of $50 for medication management. There is a $50 no show fee for existing patient medication management appointments. The credit card on file will be charged automatically.
A urine drug screening is required for ALL medication management new patients and can be requested at any time at a follow-up visit at the discretion of your provider. The cost of this screening is $15.
Patients with 3 or more missed/cancelled appointments may be considered for possible termination from our practice.
Patient responsibility is due at the time of service. The card on file will be charged the morning of your appointment.
A follow up appointment is required to obtain medication refills. If for any reason a medication refill is approved by our provider prior to a follow up appointment, a fee of $25 will be automatically charged to the card on file for any medication refills, dosing/medication change or pharmacy change.
All insurance, address, phone number, and pharmacy changes need to be updated with our office.
Disability cases will NOT be completed at our office.
We require at least 48 hour notice (business days) for any talk therapy appointment cancellations. Failure to do so will result in a $100 cancellation fee. There is a therapy no-show fee of $100. The credit card on file will be charged automatically.

Financial Policies and Benefit Assignment

I authorize Georgia Psychiatry and Sleep to furnish information as necessary to my insurance carrier regarding my illness and treatment, and I assign to Georgia Psychiatry and Sleep all insurance payments for medical services rendered. I understand that I am responsible for providing all necessary information to the office or submitting charges to the insurance company for payment. If I fail to provide this information, I accept the financial responsibility of payment for services rendered. This office has a cancellation policy that requires 24-hour advance notification. I understand that if I cancel with less than 24-hour notice, a charge will be made for the time reserved. This charge is not covered by insurance and is not payable from any insurance company.
Consent to Treatment with Psychotropic Medications

The indications for the medication(s) that are a part of my treatment plan have been discussed with me. I understand that, on occasion, some psychotropic medications may be used for psychiatric conditions or symptoms, despite a lack of FDA approval for these uses. I accept this and accept the advantages and disadvantages of this treatment. Based on the information provided, I agree to comply with the instructions provided by my physician.

If I have further questions or concerns about the medication(s) or treatment, I understand that I should contact the prescribing physician as soon as possible.
Drug Screen Policy

At the initial evaluation and from time to time during treatment, patients may be asked to submit a urine specimen for analysis for drugs. The results of these look to see if in fact the patient is taking medications prescribed and also to verify that the patient is not using other unauthorized substances. For the wellbeing and health of our patients, the screening will also help to determine there are no dangerous interactions between multiple drugs.

We will collect a $15 office supply fee upon scheduling your initial evaluation to cover the cost of supplies for the urine sample. Future drug screenings may be required and is at the discrestion of your provider. The processing of the urine sample by the lab is normally covered by insurance, however, there may be a copay or balance owed after the insurance pays. It is the responsibility of the patient to take care of any addtional fees owed to the lab for the processing of the urine sample.

By your signature below, you indicate that you have read, understand, and agree with this policy. This document will be scanned into your permanent medical records and you may request a copy of it for your own files.
Consent to Treatment with Telemedicine

By signing this form, you agree that you have read, understand, and agree with these terms if scheduled for a telemedicine appointment. By signing below, I acknowledge the following:

I am aware of the provider that I am scheduled to have my telemedicine appointment with.

I have been able to ask questions about telemedicine sessions with GPS staff.

I am aware that I can reach out to the office if I have any questions.

I understand that no guarantees have been made about the success or outcome, and I agree to take part in a telemedicine appointment.

I understand that the telemedicine consultation will be similar to a routine medical office visit.

I understand that this is an option on a temporary basis due to the COVID-19 Pandemic.
Consent for the Use of AI Technology During Medical Session

This technology creates accurate notes from the ambient conversation between providers and client. The primary purpose of this technology allows provider to focus on Client care while still maintaining accurate and timely documentation.

Our office assures the compliance of applicable federal, state, and local laws and regulations, including HIPAA with the use of AI technology.

Client has the right to refuse the use of AI technology at any point with written request.
Click here to access patients' rights and responsibilities.

Click here to access Disclosure Limited to Session for Therapy Services
I have received and read the full office policies, financial policy, disclosure limited to therapy services and patients' rights and responsibilities documents. This is a separate series of documents that further outlines our full office policies. A copy of these forms can be viewed and downloaded using the above links. *

Clear
I give consent to retrieve and release records to care providers within my treatment circle.*

YesNo

Scales/Questionnaires

PHQ 9 - Over the last 2 weeks, how often have you been bothered by any of the following problems?*

	Not at all (0)	Several Days (1)	More than half of the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching TV
Moving or speaking so slowly that other people have noticed? Or the opposite- being so fidgety/restless that you have been moving around more than usual
Thoughts that you would be better off dead or hurting yourself in some way

PHQ Total
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult

GAD 7 - Over the last 2 weeks, how often have you been bothered by the following problems?*

	Not at all (0)	Several Days (1)	More than half the days (2)	Nearly every day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

GAD Total

ASRS*

	Never	Rarely	Sometimes	Often	Very Often
How often do you have trouble wrapping up the final detail of a project, once the challenging parts have been done?
How often do you have difficulty getting things done when you have to do a task that requires organization?
How often do you have trouble remembering appointments or obligations?
When you have a task that requires a lot of thought, how often do you avoid/delay getting started?
How often do you fidget or squirm with your hands/feet when you have to sit down for a long time?
How often do you feel overly active and compelled to do things, like you were driven by a motor?

Total

ESS - How likely are you to doze off/fall asleep in the following situations, in contrast to just feeling tired?*

	Least Likely (0)	Somewhat likely (1)	Likely (2)	Most likely (3)
Sitting and relaxing
Watching TV
Sitting inactive in a public place (Ex: in a meeting or theater)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped for a few minutes in traffic

Total

MDQ*

	Yes	No
Has there ever been a period of time when you were not your usual self?
You felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
You were so irritable that you shouted at people or started arguments/fights?
You felt much more self confident than usual
You got much less sleep than usual and found that you didn't really miss it?
You were much more talkative or spoke much faster than usual?
Thoughts raced through your head or you couldn't slow your mind down?
You were so easily distracted by things around you that you had trouble concentrating or staying on track?
Had much more energy than usual?
You were much more active or did many more things than usual?
You were much more social or outgoing than usual?
You were much more interested in sex than usual?
You did things that were unusual for you or that other people thought were excessive, foolish, risky?
Spending money got you or your family in trouble?

Total*
If you answered yes to more than one above, have several of these ever happened during the same period of time?*

YesNo
How much of a problem did any of these cause you? Like being unable to work, having family/money/legal troubles, getting into arguments/fights?*

No problemMinor problemModerate problemSerious problem
Have any of your blood relatives had manic-depressive illness or bipolar disorder?*

YesNo
Has a healthcare professional ever told you that you have manic-depressive illness or bipolar disorder?*

YesNo

RMS *

	Yes	No
Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?
Did you have problems with depression before the age of 18?
Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy, unusually outgoing, or unusually energetic?
Have you ever had a period of at least 1 week during which you needed less sleep than usual?

Total*
How often do you have drinks containing alcohol?*

NeverMonthly or less2-4 times a month2-3 times a week4 or more times a week
How many standard drinks containing alcohol do you have on a typical day?*

01-23-45-67-910 or more
How often do you have six or more drinks on one occasion?*

NeverLess than monthlyMonthlyWeeklyDaily or almost daily

Sleep Routine Questionnaire*

	Yes	No
Do you work shifts?
Do you feel your work, home, social life is affected by your shifts?
Do you feel tired/sleepy when you need to be awake?
Do you snore loudly on most nights?
Do you have morning headaches?
Does anyone in your family snore loudly or have sleep apnea?
Have you, as a driver, been in a car accident because of sleepiness?
Have you ever sleepwalked as an adult?
Do you have creepy, crawly legs at nights that keep you awake most nights of the week?
Do you have "sleep attacks" during the day while laughing or experiencing strong emotions?

Any major medical (non-psychiatric) hospital admissions?*

YesNo
If yes, please provide hospital name, dates seen, and reason.*
Type N/A if not applicable
Any major surgeries?*
If yes, what/when? Type N/A if not applicable
Do you ever hear voices or experience hallucinations? Or have you in the past?*

YesNo
If yes, please provide date of last occurrence and details. *
Type N/A if not applicable
Do you have a history of addiction?*

YesNoOngoingPast

What is/was your substance of choice:*

	Yes	No
Alcohol
Marijuana
Opiates
Cocaine
Meth
Kratom

If other, please specify*
Type N/A if not applicable
Most recent use*
Provide date. Type N/A if not applicable
Have you ever experienced drug withdrawals/substance use-related seizures?*

YesNo
If you have an active addiction, what is your longest period of sobriety?*
Type N/A if not applicable
What was the age or year of your first time use of any substances?*
Type N/A if not applicable
Do you attend AA/NA/12-Step meetings?*

YesNo

Review of Systems*

	Yes	No
Generally healthy
Changes in weight or changes in strength/exercise tolerance
Headaches, vertigo, head injury
Changes in hearing, ringing in ears, bleeding in ears, vertigo
Nose bleeds, colds, congestion/discharge
Dental difficulties, gingival bleeding, use of dentures
Chest pain, palpitations, fainting, shortness of breath, irregular heartbeat
Change in appetite, abdominal pains, bowel habit changes
Urinary urgency, painful urination, change in nature of urine
Change in menses, cramping, pelvic pain
Pain in muscles/joints, limitation of range of motion, tingling or numbness
Weakness, tremors, seizures, change in mental function, problems with muscle coordination
Changes in sleep habits, difficulty sleeping, insomnia

Family History*

	Self	Mother	Father	Sibling
Bipolar disorder
Depression
Anxiety
Addiction
ADHD
Schizophrenia
Family history of completed suicide
Heart Disease/Structural heart defects
Sudden cardiac death (sudden heart attack in 20s/30s)
Heart arrhythmias
Seizures
High blood pressure
Thyroid disease
Kidney disease
Liver disease (Hepatitis/Cirrhosis)
Sleep Apnea
Narcolepsy
Autoimmune disease
Diabetes
Coronary Artery Disease
Congestive Heart Failure
Stroke
NONE OF THESE APPLY

Are you currently pregnant?*

YesNoN/A
Are you currently breastfeeding or pumping breast milk for infant feedings?*

YesNoN/A
Please list any other chronic medical conditions you have.*
Type N/A if not applicable
Do you smoke cigarettes?*

YesNoFormer SmokerI use other forms of tobacco.
If yes/other, please specify.*
Current height*
Feet/inches
Current weight*
Lbs
What time do you wake up and go to sleep on a typical work/school day?*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
How long does it take you to fall asleep on most nights?*

Social History
Marital Status*
Number of children?*
Highest level of education?*
Employment Status*
If employed, what is your position and employer?*
"N/A" if not applicable
If on disability, is it for*

Medical conditionPsychiatric conditionI am not on disability.
Please specify *
Condition, "N/A" if not applicable

Legal History*

	Yes	No
No Legal Problems
Spent time in jail
On probation currently
Court-Ordered Treatment

If time spent in jail/prison, please give reason and total time served*
Reason, How long. Type N/A if not applicable.
Have you served in the US military?*

YesNo
If yes, how long and reason for discharge?*
Number of years served, Reason for discharge. Type N/A if not applicable

Please list ALL current medications. Make sure to list medication name, dosage, frequency, and route.*
Drug Name, Dose, Frequency, Route. Type N/A if you have no current medications
List any psychiatric medications you have tried in the past.*
Drug Name, Dose, Prescriber, Dates Used, Why did you stop? Type N/A if you have not tried any psychiatric medications in the past.
Are you allergic to any medications?*
Type N/A if not applicable.
Signature*

Clear
Today's Date *

MonthDayYear
Date

Birth Date of Child*

MonthDayYear
Sex*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Gender*

MaleFemaleNon-BinaryTransgender MTFTransgender FTM
Preferred Pronouns*

She/Her/HersHe/Him/HisThey/Their/TheirsOther

Family Information*

	Parent/Guardian 1
Name
Date of Birth
Contact Number
Can give consent to treatment? Y/N

	Parent/Guardian 2
Name
Date of Birth
Contact Number
Can give consent to treatment? Y/N

Guarantor Name*
Relationship to Child*

Release of Information (ROI)- Please list below individuals (family, spouse, friend) with whom your provider can discuss your care or release your psychiatric medical records. If you do not want to release your information to anyone, type "N/A" in the Name box and "Do not release medical information" in the Relationship Dropbox.*

	Name	Relationship	Phone Number
ROI Person #1
ROI Person #2

Preferred Pharmacy*
Provide pharmacy name
Provide pharmacy address

Insurance Company *
Insurance Member ID Number*
Attach a picture of the FRONT of your insurance card.

Cancelof
Attach a picture of the BACK of your insurance card.

Cancelof
Attach a picture of the FRONT of your Driver's License/Government-Issued ID.

Cancelof

Office Policies*

	I Acknowledge
There is a new patient no-show fee of $100. This will be required before our staff are able to reschedule an initial appointment. The credit card on file will be charged automatically.
We do require 48 hours (business day) notice for any new patient appointment cancellations. Failure to do so will result in a $100 fee that will be required before the initial appointment can be rescheduled. The credit card on file will be charged automatically.
There is an existing patient no-show fee of $50 for medication management. There is a existing patient same day cancellation fee of $50 for medication management. The credit card on file will be charged automatically.
We require at least 48 hours (business day) notice for any talk therapy appointment cancellations. Failure to do so will result in a $100 cancellation fee. There is a therapy no-show fee of $100. The credit card on file will be charged automatically.
A urine drug screening is required for ALL medication management new patients and can be requested at any time at a follow-up visit at the discretion of your provider. The cost of this screening is $15.
Patients with 3 or more missed/cancelled appointments may be considered for possible termination from our practice.
Patient responsibility is due at the time of service. The card on file will be charged the morning of your appointment.
Any medication refill requests will be considered on a case-to-case basis and must be approved by your provider. If approved without an appointment, there is a $25 refill fee. The credit card on file will be charged automatically.
All insurance, address, phone number, and pharmacy changes need to be updated with our office.
Any disability cases will NOT be filled out at an initial evaluation.
A parent or legal guardian is required to be present for a child's medication management appointment.

Consent to Treatment with Telemedicine

By signing this form, you agree that you have read, understand, and agree with these terms if scheduled for a telemedicine appointment. By signing below, I acknowledge the following:

I am aware of the provider that I am scheduled to have my telemedicine appointment with.

I have been able to ask questions about telemedicine sessions with GPS staff.

I am aware that I can reach out to the office if I have any questions.

I understand that no guarantees have been made about the success or outcome, and I agree to take part in a telemedicine appointment.

I understand that the telemedicine consultation will be similar to a routine medical office visit.

I understand that this is an option on a temporary basis due to the COVID-19 Pandemic.
Please click here to access patients' rights and responsibilities.
Drug Screen Policy

At the initial evaluation and from time to time during treatment, patients may be asked to submit a urine specimen for analysis for drugs. The results of these look to see if in fact the patient is taking medications prescribed and also to verify that the patient is not using other unauthorized substances. For the wellbeing and health of our patients, the screening will also help to determine there are no dangerous interactions between multiple drugs.

We will collect a $15 office supply fee upon scheduling your initial evaluation to cover the cost of supplies for the urine sample. Future drug screenings may be required and is at the discrestion of your provider. The processing of the urine sample by the lab is normally covered by insurance, however, there may be a copay or balance owed after the insurance pays. It is the responsibility of the patient to take care of any addtional fees owed to the lab for the processing of the urine sample.

By your signature below, you indicate that you have read, understand, and agree with this policy. This document will be scanned into your permanent medical records and you may request a copy of it for your own files.
I have received and read the full office policies, financial policy, and patients' rights and responsibilities. This is a separate series of documents that further outlines our full office policies. A copy of these forms has been emailed to you and can be provided on request.*

Clear
I give consent to retrieve and release records to care providers within my treatment circle.*

YesNo

What service are you looking to schedule?*

Medication Management (Where medication can be prescribed)Talk Therapy (Where medication cannot be prescribed)1x Psychiatric EvaluationHospital DischargeOther
We are NOT able to complete any paperwork/evaluation for court-ordered treatment or short/long term disability cases.*

I acknowledge
Reason for visit?*
What symptoms are you currently experiencing?*

Sleep DifficultyAnxietyStressBipolar symptomsDepressionWithdrawal from Substance AbusePTSDADHDPanic AttacksSchizophrenia
Have you ever seen a psychiatrist or counselor in the past?*

YesNo
If yes, please provide the name of psychiatrist, dates seen, treatment reason, and reason for seeking care elsewhere*
Name of Psychiatrist, Dates Seen, Treatment Reason, Reason for Seeking Care Elsewhere. Type N/A if not applicable
How did you find out about Georgia Psychiatry and Sleep?*

Provider referred meInternet searchFriend/RelativeInsurance ListingOther
Have you been a patient in a psychiatric hospital or in a rehab program within the past year for a drug/alcohol or behavioral problem?*

YesNo
If yes, please give name of facility, location, dates seen, type of program, and treatment reason.*
Type N/A if not applicable

PLEASE GET YOUR CHILD'S/TEEN'S INPUT IN ANSWERING THE FOLLOWING SCALES (If developmentally appropriate).

PHQ 9 - Over the last 2 weeks, how often has your child/teen been bothered by any of the following?*

	Not at all (0)	Several days (1)	More than half the days (2)	Nearly every day (3)
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep/sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself- or that you are a failure or have let yourself/your family down
Trouble concentrating on things
Moving or speaking so slowly that other people have noticed? Or the opposite- being so fidgety/restless that you have been moving around more than usual
Thoughts that you would be better off dead or hurting yourself in some way

Total*
If you checked off any problems, how difficult have these problems made it for your child/teen to do school work/activities, or get along with other people?*

Not difficult at allSomewhat difficultVery difficultExtremely difficult
In the past year, has your child/teen felt depressed or sad most days, even if they felt okay sometimes?*

YesNo
Has there been a time in the past month when your child/teen had serious thoughts about ending their life?*

YesNo
Has your child/teen ever, in their whole life, tried to kill themself or made a suicide attempt?*

YesNo

GAD 7 - Over the last 2 weeks, how often has your child/teen been bothered by the following problems?*

	Not at all (0)	Several days (1)	More than half of the days (2)	Nearly every day (3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

Total*
Please describe, if applicable, the circumstances that can cause/increase anxiety in your child/teen:*

ADHD*

	Never	Occasionally (1)	Often (2)	Very Often (3)
Does not give close attention to details or makes careless mistakes in school/work
Has difficulty sustaining attention in tasks/play activities
Does not seem to listen when spoken to directly
Does not follow through on instructions and fails to finish school work/chores (not due to oppositional behavior or failure to understand directions)
Has difficulty organizing tasks and activities
Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as school work/homework)
Loses things necessary for tasks/activities such as toys, books, assignments, etc.
Is often easily distracted
Is often forgetful in daily activities
Fidgets with hands or feet or squirms in seat
Leaves seat in classroom or in other situations in which remaining seated is expected
Runs about or climbs excessively in inappropriate situations
Has difficulty playing or engaging in leisure activities quietly
Often "on the go" or often acts as if driven by a motor
Talks excessively
Blurts out answers before questions are completed
Has difficulty waiting their turn
Interrupts/intrudes on others

Total

ESS - How likely is your child/teen to doze off or fall asleep in the following situations, in contrast to just feeling tired?*

	Least likely (0)	Somewhat Likely (1)	Likely (2)	Most Likely (3)
Sitting and reading
Sitting and watching TV or a video
Sitting in a classroom at school during the morning
Sitting and riding in a car or bus for about half an hour
Lying down to rest or nap in the afternoon
Sitting and talking to someone
Sitting quietly by yourself after lunch
Sitting and eating a meal

Total*

MDQ - Has there ever been a period of time when your child was not their usual self and...*

	Yes	No
Felt so good or hyper that you thought they were not their normal self or they were so hyper that it got them into trouble?
Was so irritable that they shouted at people or started fights/arguments?
Seemed to feel more self-confident than usual?
Got much less sleep than usual and seemed like they didn't really miss it?
Was so much more talkative or spoke much faster than usual?
Seemed as though their thoughts were racing or they couldn't slow their mind down?
Was so easily distracted by things around them that they had trouble concentrating or staying on track?
Had much more energy than usual?
Was much more active or did many more things than usual?
Was much more social or outgoing than usual?
Did things that were unusual for them or that other people might've thought were excessive, foolish, or risky?

Total*

Sleep Routine Questionnaire*

	Yes	No
Do you feel like your child's school/home/social life is negatively affected by their sleep habits?
Does your child feel tired or sleepy when they need to be awake?
Does your child snore loudly on most nights?
Does your child have morning headaches?
Does anyone in your family snore loudly or have sleep apnea?
Does your child sleep walk?
Does your child have creepy, crawly legs at night that keep them awake most nights of the week?
Does your child have "sleep attacks" during the day while laughing or experiencing strong emotions?

What is your child/teen's typical sleep schedule on a school/work day?*

Hour Minutes

AM/PM Option

Until
until
Hour Minutes

AM/PM Option
How long does it take for your child/teen to fall asleep most nights?*
Please describe your child/teen's average nighttime routine.*
Is your child generally healthy?*

YesNo

Review of Systems- Please indicate if your child/teen has a history of the following: *

	Yes	No
Abnormal changes in weight or changes in strength/exercise tolerance
Frequent headaches, head injury
Changes in hearing, ringing in ears, bleeding in ears, vertigo
Frequent nose bleeds, colds, congestion, discharge
Dental difficulties, gingival bleeding, use of dentures
Difficultly breathing, wheezing, coughing blood, cough
Chest pains, palpitations, fainting, shortness of breath, irregular heartbeat
Urinary urgency, painful urination, changes in nature of urine
Change in menses, cramping, pelvic pain
Pain in muscles/joints, limitation of range of motion, tingling, numbness
Weakness, tremors, seizures, changes in mental function, problems with muscle coordination
Changes in sleep habits, difficulty sleeping, insomnia

Has your child/teen been more irritable than usual?*

YesNo
Has your child/teen been isolating from friends/family?*

YesNo
Have your child/teen's grades dropped from their baseline?*

YesNo
Does your child/teen have behaviors that are of concerns?*

YesNo
If yes, please explain:*
Type N/A if not applicable
Does your child/teen have access to any weapons in their home(s)?*

YesNo
If yes, please explain*
Type N/A if not applicable
Does child/teen live with both biological parents?*

YesNo
If no, please explain*
Type N/A if not applicable
If parents are separated/divorced, how often does the child/teen see the other parent?*
N/A if not applicable
Who currently lives in the home with your child/teen? List all household members and age*
Family Members' Names and Age
Current marital status of parent/legal guardian?*
Number of parent/legal guardian's prior marriages*
Number of parent/legal guardian's children*
Parent/Guardian #1 - Highest level of education? *
Parent/Guardian #2- Highest level of education?
Parent/Guardian #1 Employment Status*
Parent/Guardian #1 Employer/Position*
Type Employer and Position, N/A if not applicable
Parent/Guardian #2 Employment Status
Parent/Guardian #2 Employer/Position
Type Employer and Position, N/A if not applicable
Has either parent/guardian served in the US military?*

YesNo
If yes, please specify how many years of service and reason for discharge.*
Type N/A if not applicable

Have there been any major changes in the life of your child/teen in the last few years?*

YesNo
If yes, please explain*
Type N/A if not applicable
Does your child/teen have a history of abuse, neglect, or bullying?*

YesNo
If yes, please explain*
Type N/A if not applicable
Has your child/teen ever been arrested or had charges filed against them?*

YesNo
If yes, please explain*
Type N/A if not applicable
Has your child/teen ever been cruel to other people or animals?*

YesNo
If yes, please explain*
Type N/A if not applicable
Were there any problems in the pregnancy/birth of this child/teen?*

YesNo
If yes, please explain*
Type N/A if not applicable
Did your child/teen meet all developmental milestones in a timely manner? (walking, talking, potty training, etc.)*

YesNo
If no, please explain*
Type N/A if not applicable
Has your child/teen received any special classes or assistance in school? (Special education classes, tutoring, gifted classes, etc.)*

YesNo
If yes, please explain*
Type N/A if not applicable
Does your child have any issues making or keeping friends?*

YesNo
If yes, when did this start?*
Type N/A if not applicable
What school does your child/teen attend?*
What grade are they in?*
Are there any problems in school for your child/teen?*
What are typical teacher comments about your child/teen?*

Has your child/teen abused any of the following substances?*

	Yes	No
Alcohol
Marijuana
Opiates
Cocaine
Meth
Kratom

If other substance abused, please specify:*
Type N/A if not applicable
Does your child/teen smoke or vape?*

YesNo
Does anyone in the household smoke cigarettes?*

YesNoFormer Smoker
Does anyone in the family/household have a history of addiction?*

YesNoOngoingPast
If yes, please specify the member's relationship to the child/teen, drug of choice, family member's last use, and longest period of sobriety.*
Type N/A if not applicable.
If yes, has this family member ever experienced drug withdrawals?*

YesNo

Any prior major medical (non-psychiatric) hospital admissions?*
Please give hospital name, location, dates, and reason. Type N/A if not applicable.
If applicable, when did your child/teen's first menses/period begin?*
Type N/A if not applicable
If applicable, is your teen currently pregnant?*

YesNoN/A
If applicable, is your teen breastfeeding or pumping breast milk for infant feedings?*

YesNoN/A
Has your child/teen ever severely restricted food intake or made themselves intentionally throw up or engaged in other behaviors to control their weight?*

YesNo
If yes, please explain*
Type N/A if not applicable

Family Medical History*

	Self	Mother	Father	Sibling
Bipolar
Depression
Anxiety
Addiction
ADHD
Schizophrenia
Family history of completed suicide
Heart disease/Structural cardiac heart defects
Sudden cardiac death (sudden heart attack in 20/30s)
Heart arrhythmias
Seizures
High Blood Pressure
Thyroid Disease
Kidney Disease
Liver Disease (Hepatitis/Cirrhosis)
Sleep Apnea
Narcolepsy
Autoimmune disorder
Diabetes
Coronary Artery Disease
Congestive Heart Failure
Asthma/Respiratory Illness
Stroke
NONE OF ABOVE

Does your child/teen have any other chronic medical conditions?*
Type N/A if not applicable
Child/teen's current height*
Feet/inches
Child/teen's current weight*
lbs

List ALL current medications your child/teen is taking. Make sure to list medication name, dosage, frequency, and date started.*
List medication name, dosage, prescriber, and date started. Type N/A if no current medications.
List any psychiatric medications your child/teen has tried in the past (not listed above)*
List medication name, dosage, provider dates taken, and reason for stopping. Type N/A if no past psychiatric medications.
Is your child/teen allergic to any medications?*

YesNo
If yes, please list all drug allergies*
Type N/A if not applicable.

Parent/Legal Guardian Signature*

Clear
Today's Date*

MonthDayYear
Date
Should be Empty:

Scales/Questionnaires

Social History