Oak Peak Consulting, LLC Patient/Student Information Form

Patient/Student Information Form

Oak Peak Consulting, LLC - Please complete this form if you have been referred for Youth In Crisis services and would like to see if we can place your Patient/Student. This form must FIRST be completed before we are able to get in contact with you regarding placement. We want to help you! Please take your time and fill out the form with as much detail as possible.
Potential Patient/Student Name*

First NameLast Name
DOB*

MonthDayYear
Age*
Social Security Number*
Do not add dashes to number please.
Height*
Input Total INCHES
Weight*
Input Weight in Total Pounds
Cell. Phone*
(Area Code) Phone Number
Parent/Guardian Phone Number*
(Area Code) Phone Number
Parent/Guardian Email
example@example.com
Birth Mother Name*

First NameLast Name
Birth Father Name*

First NameLast Name
Legal Guardian Full Name*

First/Middle NameLast Name
Relationship of Legal Guardian (Grandparent, Aunt, Foster Parent, etc.)*
Are the Guardians Divorced?*

YesNo
Who has custody of the Patient/Student?
If one Guardian is sending student to a Facility, is the other Guardian supportive?*

YesNo
Is the Patient/Student adopted?*

YesNo
Legal Guardian Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Where has Patient/Student been living?*
What is the Source of Funding expected to be used to pay for Treatment?

Private PayHealth Insurance CoverageMedicaidCalifornia Department of Education FundingCalifornia Adoption AssistanceTri-Care - West
Verification of Benefits
Policy Holder's Name*

First NameLast Name
Relationship to Patient*
Policy Holder Phone Number*
Please enter a valid phone number.
Policy Holder Date of Birth*

MonthDayYear
Employer of Policy Holder*
Insurance Company Name*
Insurance Company Phone Number (listed on the back of Insurance card)
Please enter a valid phone number.
Insurance ID*
Group ID*
Notes/Additional Information
Medical
List all medications, including frequency and quantity if the Patient/Student takes medications.*
Is the Patient/Student psychotic, schizophrenic, autistic, Asperger’s?*

YesNo
If yes, please explain.*
Does the Patient/Student have or have had seizures, convulsions or epilepsy?*

YesNo
If yes, please explain.
Does the Patient/Student have diabetes?*

YesNo
If yes, please provide additional information.*
Is the Patient/Student allergic to any medications? If yes, please list them.*

YesNo
List medications Patient/Student is allergic to, if any:*
Does the Patient/Student have any self-medicating issues?*

YesNo
Please explain.*
Does the Patient/Student use alcohol or marijuana?*

YesNo
If yes, is it excessive? Please explain.*
Has the Patient/Student been diagnosed with Fetal Alcohol Syndrome or had any prenatal exposure to drugs?*

YesNo
Addiitional information:*
Is there additional drug history?*
Schooling
What is the Patient/Student's last grade level completed?*
Name of last School the Patient/Student attended?*
Has Patient/Student dropped out of school?*

YesNo
Has Patient/Student been suspended or expelled from school? **

YesNo
Please explain.*
Has the Patient/Student been failing school?*

YesNo
If yes, please list subjects:*
What is Patient/Student's Reading level?*
Does Patient/Student require additional help in school?*

YesNo
If yes, please list specifications:*
Does the Patient/Student have an IEP or 504 plan?*

YesNo
If yes, please list services and accommodations:*
Does the Patient/Student have an IQ below 85?*

YesNo
If yes, please list the IQ:*
Suicidal
Has the Patient/Student been suicidal?*

YesNo
Please explain.*
Have there been verbal expressions of suicide?*

YesNo
Please explain.*
Any physical harm to self (such as cutting, eating disorders, etc.)?*

YesNo
Please explain.*
Any suicide attempts?*

YesNo
Please explain.*
If your Patient/Student went to the hospital for any of the above conditions, what did the Doctor’s note indicate? Was this an actual suicide attempt or was it attention-seeking behavior?*
Violence
Has the Patient/Student been violent with any other kids, siblings, or property?*

YesNo
Please explain.*
Has the Patient/Student been violent with Parents/Guardians?*

YesNo
Please explain.*
Has the Patient/Student been violent with Authority?*

YesNo
Please explain.*
Has the Patient/Student run away or attempted to run?*

YesNo
Please explain.*
Does the Patient/Student come and go as pleases and acts as though nothing has happened?*

YesNo
Please explain.*
Does the Patient/Student take off/run and Police have to find and bring them back?*

YesNo
Please explain.*
Has the Patient/Student ever been physically abused?*

YesNo
Please explain.*
Sexual
Is the Patient/Student sexually active?*

YesNo
Other information:*
Does the Patient/Student have a boyfriend or girlfriend or lots of partners?*

YesNo
Other information:*
Has the Patient/Student experienced any sexual deviancy, porn, or inappropriate behavior with another child?*

YesNo
Please explain:*
Does the Patient/Student have any inappropriate sexual behavior on the internet or social media?*

YesNo
Please explain:*
Has the Patient/Student ever been sexually abused?*

YesNo
Other information we should know:*
Has the Patient/Student ever been the perpetrator of sexual abuse??*

YesNo
Please explain:*
Legal
Has the Patient/Student ever been in trouble with the law?*

YesNo
Please give details:*
Has the Student/Patient ever been arrested?*

YesNo
Please give details:*
Has the Student/Patient ever been on probation?*

YesNo
Please list details.*
Has the Student/Patient ever had Court dates?*

YesNo
Please explain.*
Therapy
Has the Student/Patient been in counseling or therapy?*

YesNo
If yes, in what setting and for how long?*
Has Student/Patient been admitted into any other treatment programs?*

YesNo
If yes, what program(s)?*
Has Student/Patient attempted to run from other treatment programs?*

YesNo
If yes, please explain.*
Please list any Mental Health diagnosis.*
Health
Are there any allergies or food allergies?*

YesNo
If yes, please list:*
Does the Patient/Student have any problems with bladder control?*

YesNo
If yes, please explain.*
Does the Patient/Student have any problems with bed wetting?*

YesNo
If yes, please explain.*
Does the Patient/Student have any other medical problems? (i.e. brain injury, epilepsy, asthma, broken bones, etc.)*

YesNo
If yes, please explain.*
Miscellaneous
Does the Patient/Student have have any history of arson?*

YesNo
If yes, please explain.*
If the Patient/Student is over 185 lbs., is the Patient/Student athletic or a couch potato?*

AthleticCouch Potato
Please explain.*
What activities does the Patient/Student enjoy?*
Does the Patient/Student have any hobbies or interests?*
Does the Patient/Student have any physical limitations?*
Anything else we should know about the Patient/Student?*
Date Completed

MonthDayYear
Should be Empty:

Patient/Student Information Form

Verification of Benefits

Medical

Schooling

Suicidal

Violence

Sexual

Legal

Therapy

Health

Miscellaneous