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1
Patient's Legal Name
*
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First Name
Middle Name (Optional)
Last Name
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2
Patient's Preferred Name/ Nickname:
*
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3
Patient's Preferred Pronoun?
*
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She/ Her
He/ Him
They/ Them
I Prefer Not To Say
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4
Patient's Assigned Gender at Birth
*
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MALE
FEMALE
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5
Patient's Date of Birth
*
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-
Date
Month
Day
Year
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6
Patient's Age
*
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7
Patient's Religious Affiliation
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8
Patient's Phone Number
*
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Area Code
Phone Number
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9
Please specify the patient's race.
*
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
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10
Please describe patient's goals for treatment:
*
This field is required.
(Ex: If treatment was successful in what ways would you be able to tell?)
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11
Please describe what factors or events have lead the patient to seek treatment at this specific time:
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12
First Legal Guardian's Legal Name
*
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First Name
Middle Name (Optional)
Last Name
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13
First Legal Guardian's Relationship to the Patient
*
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14
First Legal Guardian's Phone Number
*
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Area Code
Phone Number
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15
First Legal Guardian's Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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16
Would you like to add a second legal guardian?
*
This field is required.
YES
NO
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17
Second Legal Guardian's Legal Name
*
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First Name
Middle Name (Optional)
Last Name
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18
Second Legal Guardian's Relationship to the Patient
*
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19
Second Legal Guardian's Phone Number
*
This field is required.
Area Code
Phone Number
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20
Second Legal Guardian's Address
*
This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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21
Please indicate the current marital status of the patient's parents.
*
This field is required.
Check all that apply.
Single/ Never Married
Divorced
Currently Married
Mother Remarried
Father Remarried
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22
Please describe the patient's current relationship with their mother.
*
This field is required.
Check all that apply.
Good
Mixed
Poor
Never Present
Deceased
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23
If the patient's mother is deceased, how long has it been and how old was the patient?
*
This field is required.
Ex: It has been 3 years and I was 32 years old.
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24
Please describe the patient's current relationship with their father.
*
This field is required.
Check all that apply.
Good
Mixed
Poor
Never Present
Deceased
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25
If the patient's father is deceased, how long has it been and how old was the patient?
*
This field is required.
Ex: It has been 3 years and I was 32 years old.
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26
Is there a parenting plan in place?
*
This field is required.
YES
NO
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27
Is it being followed by both parents?
*
This field is required.
YES
NO
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28
Which parent(s)/guardian(s) has/ have medical power for this child?
*
This field is required.
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29
Which parent(s)/guardian(s) has/ have full custody of this child?
*
This field is required.
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30
Please explain custody arrangement.
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
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31
Childhood Information
*
This field is required.
Select all that apply.
Outstanding Home Environment
Normal Home Environment
Chaotic or Poor Home Environment
Witnessed Abuse
Experienced Abuse
Moved Often
Neglected
Traumatic Events
Did Not Live With Parents
Foster Care
Homelessness
Other
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32
Support System
*
This field is required.
Please choose all that apply.
Supportive Friends
No or Few Friends
Unsupportive Friends
Substance-use-based Friends
Supportive Family
Unsupportive Family
Distant from Family
Supportive Significant Other
Unsupportive Significant Other
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33
Sexual History
*
This field is required.
Please choose all that apply.
Heterosexual
Homosexual
Bisexual
Other
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34
Social Activities
*
This field is required.
Please choose all that apply.
Enjoy Volunteering
Board Games
Attend Church Groups
Scouts
Friends
Team Sports
Other
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35
Hobbies:
*
This field is required.
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36
Does the patient have any children?
*
This field is required.
YES
NO
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37
Children
Please list information about all of your children
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38
Does the patient have any siblings?
*
This field is required.
YES
NO
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39
Birth Order
*
This field is required.
I am the _____ (st/nd/rd/th) sibling in a line of _____ siblings.
Ex: I am the 1st sibling in a line of 3 siblings.
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40
Sibling Information
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41
Current Living Arrangements
*
This field is required.
Please choose all that currently apply.
Housing Adequate
Overcrowded
Homeless
Dysfunctional
Dependent On Others For Housing
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42
Please list all persons currently living in household.
*
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43
Has the patient had any previous counseling or medication treatment?
*
This field is required.
YES
NO
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44
If yes, who did they see, was it beneficial, and what was the reason for termination?
*
This field is required.
Please list all past care.
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45
Has the patient had previous inpatient treatment?
*
This field is required.
YES
NO
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46
If yes, when was it beneficial and at what facility?
*
This field is required.
Please list all previous care.
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47
Mental Health Symptoms
Please indicate the symptoms you (the patient) are CURRENTLY experiencing and HOW LONG you (the patient) have experienced them
Just recently
In the last year
Several Years
Most of my life
Never
Low energy
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Depression
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Waking up in the night
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Trouble falling asleep
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Sleeping too much
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Low self-esteem
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Self-Harm
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Crying often
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Feelings of guilt
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Feeling worthless
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Loss of interest
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Withdrawing from others
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Anxiety/ Fears
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Worries/ Mind racing
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Repeating actions
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Loss of focus
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Hyper- too much energy
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Row 16, Column 3
Row 16, Column 4
Moodiness
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Row 17, Column 3
Row 17, Column 4
Difficulty Concentrating
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Row 18, Column 3
Row 18, Column 4
Anger/Temper Issues
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Row 19, Column 3
Row 19, Column 4
Physical chronic pain
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Row 20, Column 3
Row 20, Column 4
Weight change
Row 21, Column 0
Row 21, Column 1
Row 21, Column 2
Row 21, Column 3
Row 21, Column 4
Appetite change
Row 22, Column 0
Row 22, Column 1
Row 22, Column 2
Row 22, Column 3
Row 22, Column 4
Stomach Issues
Row 23, Column 0
Row 23, Column 1
Row 23, Column 2
Row 23, Column 3
Row 23, Column 4
Frequent headaches
Row 24, Column 0
Row 24, Column 1
Row 24, Column 2
Row 24, Column 3
Row 24, Column 4
Constipation/Diarrhea
Row 25, Column 0
Row 25, Column 1
Row 25, Column 2
Row 25, Column 3
Row 25, Column 4
Gambling Issues
Row 26, Column 0
Row 26, Column 1
Row 26, Column 2
Row 26, Column 3
Row 26, Column 4
Financial Stress
Row 27, Column 0
Row 27, Column 1
Row 27, Column 2
Row 27, Column 3
Row 27, Column 4
Substance Abuse Issues
Row 28, Column 0
Row 28, Column 1
Row 28, Column 2
Row 28, Column 3
Row 28, Column 4
Sexual problems
Row 29, Column 0
Row 29, Column 1
Row 29, Column 2
Row 29, Column 3
Row 29, Column 4
Nightmares
Row 30, Column 0
Row 30, Column 1
Row 30, Column 2
Row 30, Column 3
Row 30, Column 4
Family Violence
Row 31, Column 0
Row 31, Column 1
Row 31, Column 2
Row 31, Column 3
Row 31, Column 4
Physical Abuse
Row 32, Column 0
Row 32, Column 1
Row 32, Column 2
Row 32, Column 3
Row 32, Column 4
Sexual Abuse
Row 33, Column 0
Row 33, Column 1
Row 33, Column 2
Row 33, Column 3
Row 33, Column 4
Inappropriate Sexual Behaviors
Row 34, Column 0
Row 34, Column 1
Row 34, Column 2
Row 34, Column 3
Row 34, Column 4
Perpetrator of Abuse
Row 35, Column 0
Row 35, Column 1
Row 35, Column 2
Row 35, Column 3
Row 35, Column 4
Employment Issues
Row 36, Column 0
Row 36, Column 1
Row 36, Column 2
Row 36, Column 3
Row 36, Column 4
Troubles at School
Row 37, Column 0
Row 37, Column 1
Row 37, Column 2
Row 37, Column 3
Row 37, Column 4
Parent/Child conflict
Row 38, Column 0
Row 38, Column 1
Row 38, Column 2
Row 38, Column 3
Row 38, Column 4
Relationship Issues
Row 39, Column 0
Row 39, Column 1
Row 39, Column 2
Row 39, Column 3
Row 39, Column 4
Family conflict
Row 40, Column 0
Row 40, Column 1
Row 40, Column 2
Row 40, Column 3
Row 40, Column 4
Low energy
Depression
Waking up in the night
Trouble falling asleep
Sleeping too much
Low self-esteem
Self-Harm
Crying often
Feelings of guilt
Feeling worthless
Loss of interest
Withdrawing from others
Anxiety/ Fears
Worries/ Mind racing
Repeating actions
Loss of focus
Hyper- too much energy
Moodiness
Difficulty Concentrating
Anger/Temper Issues
Physical chronic pain
Weight change
Appetite change
Stomach Issues
Frequent headaches
Constipation/Diarrhea
Gambling Issues
Financial Stress
Substance Abuse Issues
Sexual problems
Nightmares
Family Violence
Physical Abuse
Sexual Abuse
Inappropriate Sexual Behaviors
Perpetrator of Abuse
Employment Issues
Troubles at School
Parent/Child conflict
Relationship Issues
Family conflict
Just recently
Row 0, Column 0
In the last year
Row 0, Column 1
Several Years
Row 0, Column 2
Most of my life
Row 0, Column 3
Never
Row 0, Column 4
Just recently
Row 1, Column 0
In the last year
Row 1, Column 1
Several Years
Row 1, Column 2
Most of my life
Row 1, Column 3
Never
Row 1, Column 4
Just recently
Row 2, Column 0
In the last year
Row 2, Column 1
Several Years
Row 2, Column 2
Most of my life
Row 2, Column 3
Never
Row 2, Column 4
Just recently
Row 3, Column 0
In the last year
Row 3, Column 1
Several Years
Row 3, Column 2
Most of my life
Row 3, Column 3
Never
Row 3, Column 4
Just recently
Row 4, Column 0
In the last year
Row 4, Column 1
Several Years
Row 4, Column 2
Most of my life
Row 4, Column 3
Never
Row 4, Column 4
Just recently
Row 5, Column 0
In the last year
Row 5, Column 1
Several Years
Row 5, Column 2
Most of my life
Row 5, Column 3
Never
Row 5, Column 4
Just recently
Row 6, Column 0
In the last year
Row 6, Column 1
Several Years
Row 6, Column 2
Most of my life
Row 6, Column 3
Never
Row 6, Column 4
Just recently
Row 7, Column 0
In the last year
Row 7, Column 1
Several Years
Row 7, Column 2
Most of my life
Row 7, Column 3
Never
Row 7, Column 4
Just recently
Row 8, Column 0
In the last year
Row 8, Column 1
Several Years
Row 8, Column 2
Most of my life
Row 8, Column 3
Never
Row 8, Column 4
Just recently
Row 9, Column 0
In the last year
Row 9, Column 1
Several Years
Row 9, Column 2
Most of my life
Row 9, Column 3
Never
Row 9, Column 4
Just recently
Row 10, Column 0
In the last year
Row 10, Column 1
Several Years
Row 10, Column 2
Most of my life
Row 10, Column 3
Never
Row 10, Column 4
Just recently
Row 11, Column 0
In the last year
Row 11, Column 1
Several Years
Row 11, Column 2
Most of my life
Row 11, Column 3
Never
Row 11, Column 4
Just recently
Row 12, Column 0
In the last year
Row 12, Column 1
Several Years
Row 12, Column 2
Most of my life
Row 12, Column 3
Never
Row 12, Column 4
Just recently
Row 13, Column 0
In the last year
Row 13, Column 1
Several Years
Row 13, Column 2
Most of my life
Row 13, Column 3
Never
Row 13, Column 4
Just recently
Row 14, Column 0
In the last year
Row 14, Column 1
Several Years
Row 14, Column 2
Most of my life
Row 14, Column 3
Never
Row 14, Column 4
Just recently
Row 15, Column 0
In the last year
Row 15, Column 1
Several Years
Row 15, Column 2
Most of my life
Row 15, Column 3
Never
Row 15, Column 4
Just recently
Row 16, Column 0
In the last year
Row 16, Column 1
Several Years
Row 16, Column 2
Most of my life
Row 16, Column 3
Never
Row 16, Column 4
Just recently
Row 17, Column 0
In the last year
Row 17, Column 1
Several Years
Row 17, Column 2
Most of my life
Row 17, Column 3
Never
Row 17, Column 4
Just recently
Row 18, Column 0
In the last year
Row 18, Column 1
Several Years
Row 18, Column 2
Most of my life
Row 18, Column 3
Never
Row 18, Column 4
Just recently
Row 19, Column 0
In the last year
Row 19, Column 1
Several Years
Row 19, Column 2
Most of my life
Row 19, Column 3
Never
Row 19, Column 4
Just recently
Row 20, Column 0
In the last year
Row 20, Column 1
Several Years
Row 20, Column 2
Most of my life
Row 20, Column 3
Never
Row 20, Column 4
Just recently
Row 21, Column 0
In the last year
Row 21, Column 1
Several Years
Row 21, Column 2
Most of my life
Row 21, Column 3
Never
Row 21, Column 4
Just recently
Row 22, Column 0
In the last year
Row 22, Column 1
Several Years
Row 22, Column 2
Most of my life
Row 22, Column 3
Never
Row 22, Column 4
Just recently
Row 23, Column 0
In the last year
Row 23, Column 1
Several Years
Row 23, Column 2
Most of my life
Row 23, Column 3
Never
Row 23, Column 4
Just recently
Row 24, Column 0
In the last year
Row 24, Column 1
Several Years
Row 24, Column 2
Most of my life
Row 24, Column 3
Never
Row 24, Column 4
Just recently
Row 25, Column 0
In the last year
Row 25, Column 1
Several Years
Row 25, Column 2
Most of my life
Row 25, Column 3
Never
Row 25, Column 4
Just recently
Row 26, Column 0
In the last year
Row 26, Column 1
Several Years
Row 26, Column 2
Most of my life
Row 26, Column 3
Never
Row 26, Column 4
Just recently
Row 27, Column 0
In the last year
Row 27, Column 1
Several Years
Row 27, Column 2
Most of my life
Row 27, Column 3
Never
Row 27, Column 4
Just recently
Row 28, Column 0
In the last year
Row 28, Column 1
Several Years
Row 28, Column 2
Most of my life
Row 28, Column 3
Never
Row 28, Column 4
Just recently
Row 29, Column 0
In the last year
Row 29, Column 1
Several Years
Row 29, Column 2
Most of my life
Row 29, Column 3
Never
Row 29, Column 4
Just recently
Row 30, Column 0
In the last year
Row 30, Column 1
Several Years
Row 30, Column 2
Most of my life
Row 30, Column 3
Never
Row 30, Column 4
Just recently
Row 31, Column 0
In the last year
Row 31, Column 1
Several Years
Row 31, Column 2
Most of my life
Row 31, Column 3
Never
Row 31, Column 4
Just recently
Row 32, Column 0
In the last year
Row 32, Column 1
Several Years
Row 32, Column 2
Most of my life
Row 32, Column 3
Never
Row 32, Column 4
Just recently
Row 33, Column 0
In the last year
Row 33, Column 1
Several Years
Row 33, Column 2
Most of my life
Row 33, Column 3
Never
Row 33, Column 4
Just recently
Row 34, Column 0
In the last year
Row 34, Column 1
Several Years
Row 34, Column 2
Most of my life
Row 34, Column 3
Never
Row 34, Column 4
Just recently
Row 35, Column 0
In the last year
Row 35, Column 1
Several Years
Row 35, Column 2
Most of my life
Row 35, Column 3
Never
Row 35, Column 4
Just recently
Row 36, Column 0
In the last year
Row 36, Column 1
Several Years
Row 36, Column 2
Most of my life
Row 36, Column 3
Never
Row 36, Column 4
Just recently
Row 37, Column 0
In the last year
Row 37, Column 1
Several Years
Row 37, Column 2
Most of my life
Row 37, Column 3
Never
Row 37, Column 4
Just recently
Row 38, Column 0
In the last year
Row 38, Column 1
Several Years
Row 38, Column 2
Most of my life
Row 38, Column 3
Never
Row 38, Column 4
Just recently
Row 39, Column 0
In the last year
Row 39, Column 1
Several Years
Row 39, Column 2
Most of my life
Row 39, Column 3
Never
Row 39, Column 4
Just recently
Row 40, Column 0
In the last year
Row 40, Column 1
Several Years
Row 40, Column 2
Most of my life
Row 40, Column 3
Never
Row 40, Column 4
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48
Diagnosis History
Please indicate if you (the patient) or a family member has been diagnosed with any of the following:
Myself
Parent
Grandparent
Sibling
Child
Depression
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Row 0, Column 4
Anxiety
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Row 1, Column 4
ADD/ADHD
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
Row 2, Column 4
PTSD
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Row 3, Column 4
Autism
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Row 4, Column 4
Conduct Disorder
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Row 5, Column 4
Eating Disorders
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Row 6, Column 4
Schizophrenia
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
Row 7, Column 4
Substance Abuse Disorder
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Row 8, Column 4
Personality Disorders
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Row 9, Column 4
Obsessive Compulsive Disorder
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Row 10, Column 3
Row 10, Column 4
Bipolar Disorder
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Row 11, Column 3
Row 11, Column 4
Learning Disorders
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Row 12, Column 3
Row 12, Column 4
Infertility
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Row 13, Column 3
Row 13, Column 4
Depression
Anxiety
ADD/ADHD
PTSD
Autism
Conduct Disorder
Eating Disorders
Schizophrenia
Substance Abuse Disorder
Personality Disorders
Obsessive Compulsive Disorder
Bipolar Disorder
Learning Disorders
Infertility
Myself
Row 0, Column 0
Parent
Row 0, Column 1
Grandparent
Row 0, Column 2
Sibling
Row 0, Column 3
Child
Row 0, Column 4
Myself
Row 1, Column 0
Parent
Row 1, Column 1
Grandparent
Row 1, Column 2
Sibling
Row 1, Column 3
Child
Row 1, Column 4
Myself
Row 2, Column 0
Parent
Row 2, Column 1
Grandparent
Row 2, Column 2
Sibling
Row 2, Column 3
Child
Row 2, Column 4
Myself
Row 3, Column 0
Parent
Row 3, Column 1
Grandparent
Row 3, Column 2
Sibling
Row 3, Column 3
Child
Row 3, Column 4
Myself
Row 4, Column 0
Parent
Row 4, Column 1
Grandparent
Row 4, Column 2
Sibling
Row 4, Column 3
Child
Row 4, Column 4
Myself
Row 5, Column 0
Parent
Row 5, Column 1
Grandparent
Row 5, Column 2
Sibling
Row 5, Column 3
Child
Row 5, Column 4
Myself
Row 6, Column 0
Parent
Row 6, Column 1
Grandparent
Row 6, Column 2
Sibling
Row 6, Column 3
Child
Row 6, Column 4
Myself
Row 7, Column 0
Parent
Row 7, Column 1
Grandparent
Row 7, Column 2
Sibling
Row 7, Column 3
Child
Row 7, Column 4
Myself
Row 8, Column 0
Parent
Row 8, Column 1
Grandparent
Row 8, Column 2
Sibling
Row 8, Column 3
Child
Row 8, Column 4
Myself
Row 9, Column 0
Parent
Row 9, Column 1
Grandparent
Row 9, Column 2
Sibling
Row 9, Column 3
Child
Row 9, Column 4
Myself
Row 10, Column 0
Parent
Row 10, Column 1
Grandparent
Row 10, Column 2
Sibling
Row 10, Column 3
Child
Row 10, Column 4
Myself
Row 11, Column 0
Parent
Row 11, Column 1
Grandparent
Row 11, Column 2
Sibling
Row 11, Column 3
Child
Row 11, Column 4
Myself
Row 12, Column 0
Parent
Row 12, Column 1
Grandparent
Row 12, Column 2
Sibling
Row 12, Column 3
Child
Row 12, Column 4
Myself
Row 13, Column 0
Parent
Row 13, Column 1
Grandparent
Row 13, Column 2
Sibling
Row 13, Column 3
Child
Row 13, Column 4
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49
Suicide Risk Screen
*
This field is required.
If there is currently any suicide risk please seek help and call the National Suicide Hotline at 1-800-273-8255
None
Yes, Recently
Yes, In the past
Suicidal Thoughts?
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Suicidal Attempts?
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Suicidal Threats?
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Suicidal Thoughts?
Suicidal Attempts?
Suicidal Threats?
None
Row 0, Column 0
Yes, Recently
Row 0, Column 1
Yes, In the past
Row 0, Column 2
None
Row 1, Column 0
Yes, Recently
Row 1, Column 1
Yes, In the past
Row 1, Column 2
None
Row 2, Column 0
Yes, Recently
Row 2, Column 1
Yes, In the past
Row 2, Column 2
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If you responded "yes" to any of the previous questions please explain the nature of the thoughts, attempts, and/or threats.
*
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If you responded "none" to all questions please write n/a.
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51
Does the patient currently use drugs or drink alcohol?
*
This field is required.
(This includes social drinking and any prescription drug not prescribed to you)
YES
NO
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52
Has the patient's family ever felt that the patient should cut down on the their drinking or drug use?
YES
NO
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53
Have friends or family annoyed the patient by criticizing their drinking or drug use?
YES
NO
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54
Has the patient ever felt bad or guilty about their drinking or drug use?
YES
NO
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55
Has the patient ever drank or used drugs in the morning to steady or their nerves or get rid of a hangover?
YES
NO
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56
Has the patient's relationships with friends or family members been negatively influenced by their drinking or drug use?
YES
NO
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57
Please specify the patient's current employment/disability status.
*
This field is required.
Employed
Full-Time Student
Disabled for A Physical Condition
Disabled for A Mental Disability
Disabled for Both Physical and Mental Disabilities
Unemployed With No Disability
None of these
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58
Current Employer Information
*
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Who is your current employer?
What is your current position at your job?
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59
How long has the patient been unemployed/disabled?
*
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60
Legal Information
*
This field is required.
Please choose all that apply.
No Legal History
Substance Related Charges
Court Ordered Therapy
Felony Charges
Domestic/Assault Charges
Arrested
Jail Time Served
Currently On Parole or Probation
Ran Away from Home
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61
How many times has the patient ran away?
*
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62
How many times has the patient been arrested?
*
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63
How many times has the patient served jail time?
*
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64
What is the name of the patient's probation officer?
*
This field is required.
First Name
Last Name
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65
What is the patient's current grade level?
*
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66
What school does the patient currently attend?
*
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67
What is the name of the patient's current school teacher?
*
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68
What has the patient experienced while at school?
*
This field is required.
Bullying
Teacher Conflict
Poor Grades
Peer Conflict
Other
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69
Please explain any current issues at school:
*
This field is required.
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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70
Did/does the patient have any learning disabilities?
*
This field is required.
YES
NO
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71
Did/ does the patient participate in a Special Education program?
*
This field is required.
YES
NO
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72
Has/ does the patient attend an Alternative School?
*
This field is required.
YES
NO
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73
What was the name of the Alternative School?
*
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74
Has the patient ever been expelled, suspended, or retained?
*
This field is required.
YES
NO
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75
School History
*
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76
Developmental Milestones
*
This field is required.
Above Average (ex: walked and talked before most)
Average (ex: walked and talked at the same level as peers)
Below Average (ex: walked and talked later than most)
I am not sure.
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77
Does the patient smoke?
*
This field is required.
YES
NO
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78
How much does the patient smoke per day?
*
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79
Has the patient or any family members been diagnosed with any of the following:
Myself
Parent
Child
Grandparent
Diabetes
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Row 0, Column 3
Head Injury/TBI
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Row 1, Column 3
Thyroid Disease
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Row 2, Column 3
HIV/AIDS
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Row 3, Column 3
Stroke
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Row 4, Column 3
Birth Defects
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Row 5, Column 3
Cancer
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Row 6, Column 3
Heart Disease
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Row 7, Column 3
High Blood Pressure
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Row 8, Column 3
Alzheimer's/Dementia
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Row 9, Column 3
Diabetes
Head Injury/TBI
Thyroid Disease
HIV/AIDS
Stroke
Birth Defects
Cancer
Heart Disease
High Blood Pressure
Alzheimer's/Dementia
Myself
Row 0, Column 0
Parent
Row 0, Column 1
Child
Row 0, Column 2
Grandparent
Row 0, Column 3
Myself
Row 1, Column 0
Parent
Row 1, Column 1
Child
Row 1, Column 2
Grandparent
Row 1, Column 3
Myself
Row 2, Column 0
Parent
Row 2, Column 1
Child
Row 2, Column 2
Grandparent
Row 2, Column 3
Myself
Row 3, Column 0
Parent
Row 3, Column 1
Child
Row 3, Column 2
Grandparent
Row 3, Column 3
Myself
Row 4, Column 0
Parent
Row 4, Column 1
Child
Row 4, Column 2
Grandparent
Row 4, Column 3
Myself
Row 5, Column 0
Parent
Row 5, Column 1
Child
Row 5, Column 2
Grandparent
Row 5, Column 3
Myself
Row 6, Column 0
Parent
Row 6, Column 1
Child
Row 6, Column 2
Grandparent
Row 6, Column 3
Myself
Row 7, Column 0
Parent
Row 7, Column 1
Child
Row 7, Column 2
Grandparent
Row 7, Column 3
Myself
Row 8, Column 0
Parent
Row 8, Column 1
Child
Row 8, Column 2
Grandparent
Row 8, Column 3
Myself
Row 9, Column 0
Parent
Row 9, Column 1
Child
Row 9, Column 2
Grandparent
Row 9, Column 3
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80
Is the patient currently taking any medications?
*
This field is required.
YES
NO
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81
Has the patient ever taken medications in the past?
*
This field is required.
YES
NO
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82
Medication List
*
This field is required.
Please list any and all medication you are currently taking/ have taken (including over the counter medications)
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83
Is the patient allergic to any medications?
*
This field is required.
YES
NO
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84
Please list all allergies and reactions.
*
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85
Who filled out this form?
*
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86
*
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(You can ask for a copy of these Terms, Conditions, and Client Rights and Responsibilities at any time)
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87
Date
Form Completed on:
-
Date
Month
Day
Year
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