Adolescent/Child Mental Health Intake Form

Adolescent/Child Mental Health Intake Form
Patient Name*

First NameLast Name
Preferred Name/Nickname
Date of Birth*

MonthDayYear
Date
Age*
Gender Assignment*
Gender Identity*
Race*
Ethnicity*
Contact Information
Name of Person Completing Form*

First NameLast Name
Parent / Guardian Names & Relationship to Patient*
Enter the name of the minor child's legal guardian(s): e.g parents, court-appointed guardian
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Method of Communication*
Emergency Contact*
Reason(s) for Consultation

Select All That Apply

Please select all the reasons for your consultation that apply to you from the list below. If you do not see your specific reason, select "Other" and specify under "Comments."

	Reason for Consultation	Comments
ADHD Evaluation & Testing (T.O.V.A)
ADHD Managemen
Autism Spectrum Disorder
Behavioral Disorders (e.g., Conduct Disorder, Oppositional Defiant Disorder)
Alcohol or Substance Use
Anxiety
Bipolar Disorder
Depression
Eating Disorder (specify under 'Comments')
I haven't felt like myself lately, seeking professional opinion
Medical Weight Loss - Semaglutide (ages 12 and up)
Obsessive-Compulsive Disorder (OCD)
Outpatient Medication Management
Personality Disorder
Pharmacogenetic (PGx) Testing
Psychiatric Evaluation Requested by Authority
PTSD/Trauma
Schizophrenia/Hallucinations
Self-Harm /Cutting
Separation Anxiety Disorder
Suicidal Thoughts
Sleep Pattern Disturbance
Uncontrolled Anger
Other Pediatric Mental Health Concerns

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.

Symptom(s) Checklist (select all that apply)

	Current Symptom	Duration	Frequency	Treatment(s)	Consequences
Academic Decline
Agitation
Alcohol Dependence
Anhedonia (Inability to Feel Pleasure)
Anger & Irritability
Anxiety Attacks
Attention Difficulties
Avoidance
Bereavement / Grief
Bullying (as victim or perpetrator)
Change in Appetite
Clinginess
Concentration / Forgetfulness
Crying Spells
Decreased Libido
Decreased Need for Sleep
Defiance
Delusions
Depressed Mood
Detachment from Reality
Difficulty Making Friends
Difficulty with Transitions (e.g., changing schools, moving)
Disorientation
Disruptive Behavior in Class
Dissociation
Excessive Daydreaming
Excessive Energy
Excessive Guilt
Excessive Worry
Fatigue
Feelings of Worthlessness
Fidgeting
Flashbacks / Hypervigilance
Frequent Nightmares
Grandiosity
Hallucinations
Homicidal Thoughts
Hopelessness
Hyperactivity
Hypersomnia
Hypervigilance
Impulsivity
Increased Irritability
Increased Libido
Increased Risky Behavior
Insomnia
Irrational Fears
Irritability During Routine Changes
Learning Difficulties
Loss of Interest
Low Self-Esteem
Mania
Mood Swings
Obsessions / Compulsions
Oppositional Behavior
Panic Attacks
Paranoia
Physical Complaints with No Medical Cause (e.g., stomachaches, headaches)
Poor Hygiene
Psychosis
Racing Heart
Racing Thoughts
Regressive Behavior (e.g., bedwetting, thumb sucking)
Restlessness
Rumination (Repetitive Negative Thoughts)
School Avoidance/Refusal
Self-Harm / Cutting
Separation Anxiety
Sibling Rivalry
Social Withdrawal
Somatic Complaints (e.g., Unexplained Physical Symptoms)
Substance Abuse
Suicide Ideations
Suspiciousness
Tantrums
Tearfulness
Thought Blocking
Truancy
Unable to Enjoy Activities
Uncontrolled Anger
Unwanted Thoughts
Other (specify under 'Comments')
None of the Above

Treatment Goal(s)*
1. Medical History
Current Height *
Current Weight *
Do you have a Primary Care Provider?*

Yes, please provide details in the next sectionNo
Primary Care Provider
Overall Health Status*
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.*

Yes, please specify belowNo Known Allergies
Preferred Pharmacy*
List all known drug, environmental, or food allergies, your reaction, severity and when it occurred
Non-Psychiatric Medications

If you are not currently taking any prescribed or over-the-counter medications, vitamins or supplements, proceed to the next section.
Configurable list*
Past Medical History
Current Medical Problems – If you do not have any current medical conditions to report, proceed to the next section.
Please provide the diagnosis, date or year diagnosed, treatment course and treating provider /practice name
List all Non-Psychiatric Hospitalizations, Reason for Treatment and Treatment Dates
Provide name of hospital, reason for treatment, month & year, length of stay
List all Surgeries and dates
Females only*
COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

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

If you answered YES to question 2, please answer questions 3, 4, 5, 6 and 7. If NO to question 2, go directly to question 6.

	Yes	No	Comments
1. Have you wished you were dead or wished you could go to sleep and never wake up?
2. Have you actually had any thoughts of killing yourself?
3. Have you been thinking about how you might do this? e.g. “I thought about taking an overdose but I never made a specific plan as to when where or how I would actually do it….and I would never go through with it.” If yes, describe in 'Comments'
4. Have you had these thoughts and had some intention of acting on them? As opposed to “I have the thoughts but I definitely will not do anything about them.” If yes, describe in 'Comments'
5. ) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan? What was your plan? When you made this plan (or worked out these details), was any part of you thinking about actually doing it? If yes, describe in 'Comments'
5) Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?
6) Have you ever done anything, started to do anything, or prepared to do anything to end your life? Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc. If YES: Was this within the past three months?
7) Do you have access to firearms?

2. Psychiatric History
Outpatient treatment*

YesNo
Are you currently under the care of a psychiatric provider?*

YesNo
Name of Current Psychiatric Provider

First NameLast Name
Current Psychiatric Provider Phone No.
Please enter a valid phone number.
Dates of Psychiatric Treatment
e.g. 3/2022 to 6/2024
Past Psychiatric Providers and Dates of Treatment
Do you currently have a therapist or counselor?

YesNo
Name of Current Therapist or Counselor

First NameLast Name
Current Therapist or Counselor Phone No.
Please enter a valid phone number.
Dates of Treatment
e.g. 3/2022 to 6/2024
Past Therapist or Counselors and Dates of Treatment
Have you ever been hospitalized for psychiatric reasons?*

YesNo
If yes, please provide the following details for each hospitalization:
Personal history of suicide attempt, suicide ideation and/or self-harm*

YesNo
History of Ketamine/Spravato treatment?*

YesNo
History of ECT, TMS treatment?*

YesNo
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.*

No history of trauma or abusePhysical trauma or abuseSexual trauma or abuseNeglectParental trauma or abuseTrauma or abuse experienced in adulthoodTrauma or abuse experienced in childhoodTrauma related to military combatIntimate partner violenceEmotional or psychological abuseBullying or harassmentWitness to domestic violenceWitness to a traumatic event (e.g., accident, disaster)Financial abuse or exploitationCultural or racial traumaMedical trauma (e.g., traumatic hospital experience, severe illness)Religious or spiritual abuseHistorical or generational traumaTrauma related to natural disastersOnline or cyber abuseWorkplace traumaCommunity violenceI am unsure how to describe my experienceI prefer not to disclose this information at this timeI prefer to discuss this when we meetOther
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.
For each medication, please include the following details:
Have you found any psychiatric medications to be effective, either in the past or currently?

YesNo
Past Psychiatric Medications

If you have never taken any psychiatric medications, please proceed to the next section.
Please indicate the name, dose, frequency, treatment dates, efficacy, reason for stopping and side effects (if any) of each medication you have taken in the past*
Developmental History
Pregnancy and Birth
Early Developmental Milestones
Physical Development
Language and Communication
Cognitive and Emotional Development
Social Development
Sleep Patterns
Behavioral Development
Medical and Developmental Interventions
Parental Concerns
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?

YesNo
Age at the time of ADHD/ADD diagnosis
Have you ever had formal neuropsychological testing?

YesNo
Date of testing

MonthDayYear
Use 1 as the day if exact date is unknown - e.g. 04/01/2023
Diagnosing Clinician

First NameLast Name
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

YesNo
Upload ADHD Evaluation

Please upload a copy of your ADHD evaluation and any other supporting documentation prior to your scheduled consultation. You can also fax it to 617-250-8262. . All data shared through this platform is HIPAA compliant and secure.
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.
Place of Birth*
Where did you grow up?*
Were you adopted?*

YesNo
Do you have any siblings?*

YesNoHalf-siblings
Birth Order*
List your siblings name, age and gender from oldest to youngestConfigurable list*
What is the relationship status of the child's parents/primary caregiver(s)?"*
What age were your when parents/primary caregiver(s) divorced/separated?
Parent/Primary caregiver(s): Highest Level of Education
Parent/Primary caregiver(s) Employment Status
Parent/Guardian Occupation
Current Living Situation*

Live with both biological parentsLive with biological motherLive with biological fatherSplit time between both parents' homesLive with grandparent(s)Live with adult sibling(s)Live with other relatives (e.g., aunt/uncle, cousin)Live with adoptive parentsLive with foster parent(s)Live in a group home or residential facilityLive with a legal guardian (not biological parents)Other
5. Social History
Name of Current School *
Educational History*
Academic Performance*
Peer Relationships
Does the child have close friends?*

YesNo
How does the child get along with others (e.g., peers, teachers)*
Friendships (Describe)
Extra-Curricular Activities
Involvement in sports, clubs, or hobbies
Cultural & Religious Background
Cultural Background*

AfricanAfrican AmericanAsian (e.g., Chinese, Japanese, Korean, Vietnamese)Caribbean (e.g., Jamaican, Haitian, Trinidadian)Eastern European (e.g., Russian, Polish, Ukrainian)Hispanic/Latino (e.g., Mexican, Puerto Rican, Cuban, Colombian)Indigenous/Native AmericanMiddle Eastern (e.g., Arab, Persian, Israeli, Turkish)Pacific Islander (e.g., Hawaiian, Samoan, Fijian)South Asian (e.g., Indian, Pakistani, Bangladeshi, Sri Lankan)Southeast Asian (e.g., Filipino, Thai, Indonesian, Malaysian)Western European (e.g., British, French, German, Italian)Prefer not to answerOther
Religious Background*

AtheistAgnosticBuddhismChristianity (e.g., Catholic, Protestant, Orthodox)HinduismIslam (e.g., Sunni, Shia)Judaism (e.g., Reform, Orthodox, Conservative)SikhismTaoismSpiritual but not religiousIndigenous/Traditional Spiritual BeliefsNone of the abovePrefer not to answerOther
Legal & Safety Concerns
Involvement with Law Enforcement or Legal System*

Yes, specify belowNo
Legal Concerns (if any)
Safety Concerns (if any)
Additional Information: Are there any other details about the child/adolescent's social history that you would like to share?
Substance Use & Risk Behaviors
Alcohol Use *
Have you ever smoked cigarettes?*

YesNo
If yes, please provide the following details:
Tobacco Use*

Never smokerFormer smokerVape userElectronic cigarette userLight cigarette smoker (1-9 cigs/day)Moderate cigarette smoker (10-19 cigs/day)Heavy cigarette smoker (20-39 cigs/day)Very heavy cigarette smoker (40+ cigs/day)Cigar smokerPipe smokerChews tobaccoChews products containing tobaccoEx-user of moist powdered tobaccoSnuff userOther
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).

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

	Yes	Age of 1st Use	How Often	Amount Used	Route	Duration	Last Used	Consequences/Effects of Use
Alcohol
Amphetamines (e.g., Adderall, Ritalin - not prescribed)
Anabolic Steroids
Barbiturates
Benzodiazepines
Cocaine
Designer Drugs (e.g., GHB, Spice/K2, Bath Salts)
Diet Pills/Laxatives
Fentanyl
Hallucinogens (Angel Dust, Ecstasy, LSD, Mushrooms, Ketamine, MDMA)
Heroin
Inhalants (Paint, Nitrous Oxide)
Kratom
Marijuana/Hashish
Methadone
Methamphetamine
Muscle Relaxants (misused)
Opiates (e.g., Codeine, Morphine)
Over-the-counter Medications (e.g., Cough Syrup)
Pain Killers (not as prescribed)
PCP (Phencyclidine)
Stimulants (pills)
Synthetic Cannabinoids (e.g., JWH-018, JWH-073)
None of the Above

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*

YesNo
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)?*

YesNo
If yes, please indicate the family member(s) and the substance(s) involved.
Has any family member ever experienced suicidal thoughts or attempted suicide?*

YesNo
If yes, please provide details on the family member(s) and any known interventions or treatments.
Have any of your family members been hospitalized for mental health issues?*

YesNo
If yes, who was hospitalized, and for what reason?
Is there a history of developmental disorders in the family (e.g., autism, ADHD, learning disabilities)?*

YesNo
If yes, please specify the family member(s) and the diagnosis.
Have any family members been diagnosed with personality disorders (e.g., borderline personality disorder, antisocial personality disorder)?*

YesNo
If yes, please specify the family member(s) and the diagnosis.
Are there any known genetic or hereditary mental health conditions in your family?*

YesNo
If yes, please specify the family member(s) and the diagnosis.
Have any family members received psychiatric medications (e.g., antidepressants, antipsychotics)?*

YesNo
If yes, please indicate the family member(s), the medication, and for what condition.
Are there any additional mental health or behavioral concerns in your family that you think we should be aware of?
Family Medical History

Please check all that apply for both 1st and 2nd degree relatives with the following medical conditions. Indicate your relationship with the family member under 'Relationship' and provide details under 'Comments' where applicable. If none of these apply, please select "None of the Above" and move on to the next section.*

	+ Family History	Relationship?	Comments
Autoimmune Disorders (specify)
Asthma/Respiratory Problems
Cancer (specify type)
Dementia
Diabetes (Type 1 or Type 2)
Heart Disease
Hypertension
High Cholesterol
Liver Dysfunction
Sudden Cardiac Death < 40 years old
Neurological Disorders (specify)
Obesity
Stroke / intracerebral hemorrhage
Thyroid Disease (specify)
Other disorder (specify)
None of the Above

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.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Name (Parent, Guardian, or Legal Representative)*

First NameLast Name
Signature of Parent, Guardian, or Legal Representative*

Clear
Relationship to Patient (Parent, Guardian, or Legal Representative)*
Effective Date*

MonthDayYear
Date
Should be Empty:

Adolescent/Child Mental Health Intake Form

Contact Information

Reason(s) for Consultation

Current Symptom(s)

1. Medical History

Allergies

Non-Psychiatric Medications

Past Medical History

COLUMBIA-SUICIDE SEVERITY RATING SCALE (C-SSRS)

2. Psychiatric History

Trauma/Abuse History

Current Psychiatric Medications

Past Psychiatric Medications

Developmental History

ADHD Evaluation & Treatment History

4. Family Background and Childhood History:

5. Social History

Peer Relationships

Extra-Curricular Activities

Cultural & Religious Background

Legal & Safety Concerns

Substance Use & Risk Behaviors

Please Indicate Your History of Substance Use

Family Psychiatric History

Family Medical History

Authorization and Consent for Mental Health Services