Adolescent/Child Mental Health Intake Form

  • Adolescent/Child Mental Health Intake Form

  •  - -

  • Contact Information

  • Format: (000) 000-0000.

  • Reason(s) for Consultation

    Select All That Apply
  • Rows

  • Current Symptom(s)

    Please select all the current symptoms that apply to you from the list below. For each symptom selected, please provide the following details:
    • Duration: How long you have been experiencing the symptom
    • Frequency: How often you experience the symptom
    • Treatment(s) List any treatments you have tried
    • Consequences: The effects or impact of the symptom on your daily life
    • Comments: Any additional details or context you wish to provide

    If none of these symptoms apply, please select 'None of the Above' and proceed to the next section.

  • Rows

  • 1. Medical History

  • Do you have a Primary Care Provider?*

  • Allergies

  • Do you have any known drug, environmental, or food allergies. If you have no known allergies, please select 'No Known Allergies' and skip the next section.*

  • Non-Psychiatric Medications

    If you are not currently taking any prescribed or over-the-counter medications, vitamins or supplements, proceed to the next section.

  • Past Medical History

  • COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

    Please answer the following questions about your feelings over the past month
  • Rows

  • 2. Psychiatric History

  • Outpatient treatment*
  • Are you currently under the care of a psychiatric provider?*
  • Format: (000) 000-0000.
  • Do you currently have a therapist or counselor?
  • Format: (000) 000-0000.
  • Have you ever been hospitalized for psychiatric reasons?*
  • Personal history of suicide attempt, suicide ideation and/or self-harm*
  • History of Ketamine/Spravato treatment?*
  • History of ECT, TMS treatment?*

  • Trauma/Abuse History

    While this information helps us provide the best possible care, it is completely voluntary, and you may choose not to answer if you do not feel comfortable sharing at this time. All information will be kept strictly confidential.
  • Please select all the categories that apply to your personal history of trauma or abuse.*

  • Current Psychiatric Medications

    If you are not currently taking any psychiatric medication, please proceed to the next section. However, if you are, please provide a list of all current psychiatric medications you are taking.
  • Have you found any psychiatric medications to be effective, either in the past or currently?

  • Past Psychiatric Medications

    If you have never taken any psychiatric medications, please proceed to the next section.

  • Developmental History

  • ADHD Evaluation & Treatment History 

    Proceed to the next section if you are not seeking an ADHD evaluation
  • Do you have a confirmed ADHD/ADD diagnosis?
  • Have you ever had formal neuropsychological testing?
  •  - -
  • Do you have a copy of the evaluation? If yes, please provide a copy before your initial evaluation. If unavailable, request it to be sent to our clinic via fax at (617) 250-8262
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • 4. Family Background and Childhood History:

    Please note: The information gathered from these questions is confidential and used solely for the purpose of better understanding your background and informing your treatment. If any of these questions make you uncomfortable, you have the right to refuse to answer.
  • Were you adopted?*
  • Do you have any siblings?*
  • Current Living Situation*

  • 5. Social History

  • Peer Relationships

  • Does the child have close friends?*

  • Extra-Curricular Activities

  • Cultural & Religious Background

  • Cultural Background*
  • Religious Background*

  • Legal & Safety Concerns

  • Involvement with Law Enforcement or Legal System*

  • Substance Use & Risk Behaviors

  • Have you ever smoked cigarettes?*
  • Tobacco Use*

  • Please Indicate Your History of Substance Use

  • Please check off each substance if you have ever tried listed below. For each substance selected, provide the following details:

    • First Use – The age when you first used the substance.
    • Frequency of Use – How often you used the substance (e.g., occasionally, weekly, daily).
    • Amount Used – The typical quantity or dose used (e.g., five drinks/day, 1 gram/day).
    • Route of Use – The method by which you used the substance (e.g., orally, intravenously, inhaled, smoked, snorted).
    • Last Use – When you last used the substance (e.g., last week, month, year).
    • Consequences of Use – Any significant outcomes or effects resulting from your use (e.g., health issues, legal troubles, relationship impacts).
  • Rows

  • Family Psychiatric History

  • Has anyone in your immediate or extended family been diagnosed with a mental health condition (e.g., depression, anxiety, bipolar disorder, schizophrenia)? If yes, please specify the family member(s) and the condition(s) below*
  • Is there a family history of substance abuse or addiction (e.g., alcohol, drugs)?*
  • Has any family member ever experienced suicidal thoughts or attempted suicide?*
  • Have any of your family members been hospitalized for mental health issues?*
  • Is there a history of developmental disorders in the family (e.g., autism, ADHD, learning disabilities)?*
  • Have any family members been diagnosed with personality disorders (e.g., borderline personality disorder, antisocial personality disorder)?*
  • Are there any known genetic or hereditary mental health conditions in your family?*
  • Have any family members received psychiatric medications (e.g., antidepressants, antipsychotics)?*

  • Family Medical History

  • Rows

  • Authorization and Consent for Mental Health Services

  • I hereby authorize Aspire Medical Group and its practitioners to provide mental health services, including evaluations and/or treatment, for the minor child or ward named above.

    I certify that I have read this form in its entirety and fully understand its contents. I have been given the opportunity to ask questions, and all of my questions have been answered to my satisfaction.

    I have informed Aspire Medical Group of the minor child or ward’s medical history, including any known allergies, current medications, supplements, and any past adverse reactions.

    I accept the risks, conditions, and terms of the proposed treatment, and I acknowledge that the provider reserves the right to discontinue or adjust the treatment plan as necessary. I understand that failure to comply with the terms of this agreement may result in the discontinuation of treatment.

    No guarantees have been made regarding the outcome of the treatment. I acknowledge that I have the right to be informed about the procedure, alternative options, and the associated risks and benefits.

    I certify that:

    • I have read this form and fully understand its contents.
    • I have provided complete and truthful information to the best of my ability.
    • I am responsible for the payment of any services received.

    By signing this form, I agree to the terms and conditions outlined in this agreement. I agree to the use of electronic records and signatures. I acknowledge that I have read the related consumer disclosure.

    The parties acknowledge and agree that this consent form may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. Without limitation, “electronic signature” shall include faxed versions of an original signature or electronically scanned and transmitted versions (e.g., via PDF) of an original signature.

    By signing this form, I voluntarily consent to treatment and confirm that I have the legal authority to consent to treatment for the minor child or ward. I voluntarily accept the risks, conditions, and terms outlined in this document.

     

  •  - -
  •  - -
  • Should be Empty: