Medication Management Intake Form

Medication Management Intake Paperwork - Child
Child's Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
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 appetiteDecreased appetiteTrouble concentratingDifficult sleepingExcessive sleepLow MotivationIsolation from othersFatigue/low energyLow self-esteemDepressed moodTearful or crying spellsAnxietyFearHopelessnessPanicOther
Does your child currently see a therapist?*

YesNo
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?*

YesNo
Does your child use recreational drugs?*

YesNo
Does your child have suicidal thoughts?*

YesNo
Has your child ever attempted suicide?*

YesNo
Does your child have thoughts or urges to harm themselves or others?*

YesNo
Has your child ever been hospitalized for a psychiatric need?*

YesNo
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?*

CloseFull of ConflictDomineeringColdHot and coldLovingIdealReservedHostileViolentDistantOther
Is there a history of mental illness in your child's family?*

YesNo
If yes, please specify as comfortable.
Is there a history of trauma?*

YesNo
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)*

YesNo
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.*
Should be Empty:

Medication Management Intake Paperwork - Child

Presenting Concern:

History of Presenting Concern:

Family of Origin Information:

School:

Strengths: