Child In-take Form

Child In-take Form
HISTORY AND BACKGROUND QUESTIONNAIRE
We appreciate the opportunity to work with your family. The information you give us is important for our evaluation. Please note that some of the questions may not be applicable given your concerns. If that is the case, please write “NA” in that section. If you would like a downloadable PDF instead, please click here: Download Form
Patient Information
Today's Date*

MonthDayYear
Date
Name of Person Completing this Form*
Email of the Person Completing this Form*
example@example.com
Patient's Full Name*

First NameLast Name
Patient's Birthdate*

MonthDayYear
Date
Identified Gender*
Race/ethnicity/cultural identity*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Referred for evaluation by*
Do you have legal authority to bring this patient to this appointment?*

YesNo

	Yes	No	Who?
Seizures
Neurological disease
Diabetes
Thyroid problems
Hearing problems
Anxiety
Attention-deficit/hyperactivity disorder
Autism spectrum disorder
Bipolar disorder
Depression
Intellectual disability
Learning problems
Obsessive compulsive disorder
Psychosis/Schizophrenia
Speech/language problems
Tics
Alcohol abuse
Drug abuse
Problems with the law
Suicide/attempted suicide
Other

Patient Information