Medication Management Intake Paperwork - Child
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
.
Month
.
Day
Year
Date
Presenting Concern:
What brings your child to treatment at this time?
*
What are your/your child's goal(s) for treatment?
*
History of Presenting Concern:
Please check any of the following your child has experienced in the last 6 months.
*
Increased appetite
Decreased appetite
Trouble concentrating
Difficult sleeping
Excessive sleep
Low Motivation
Isolation from others
Fatigue/low energy
Low self-esteem
Depressed mood
Tearful or crying spells
Anxiety
Fear
Hopelessness
Panic
Other
Does your child currently see a therapist?
*
Yes
No
If so, please include the therapist's name and contact information.
Specify all medications and/or supplements your child is presently taking, for what reason and who the prescribing MD is (name, address and phone number).
*
Specify all psychiatric medications your child has previously tried and why they were discontinued.
*
Who is your child's primary care physician? Please include the type of MD, name and phone number.
*
Does your child drink alcohol?
*
Yes
No
Does your child use recreational drugs?
*
Yes
No
Does your child have suicidal thoughts?
*
Yes
No
Has your child ever attempted suicide?
*
Yes
No
Does your child have thoughts or urges to harm themselves or others?
*
Yes
No
Has your child ever been hospitalized for a psychiatric need?
*
Yes
No
If yes, please include when and where.
Family of Origin Information:
Describe the child’s current living situation:
*
How would you describe the relationship between your child's parents/caregivers?
*
Close
Full of Conflict
Domineering
Cold
Hot and cold
Loving
Ideal
Reserved
Hostile
Violent
Distant
Other
Is there a history of mental illness in your child's family?
*
Yes
No
If yes, please specify as comfortable.
Is there a history of trauma?
*
Yes
No
If yes, please specify as comfortable.
What do you think are the child's strengths?
*
Please describe the major activities and interests of the child.
*
School:
What school does your child currently attend, who is their teacher and grade?
*
Does your child receive any special services? (IEP, 504)
*
Yes
No
If yes, please list.
How would you describe your child's peer relationships/friendships?
*
Strengths:
What do you think are your child's strengths?
*
Please describe the major activities and interests of your child.
*
Preview PDF
Submit
Should be Empty: