New Minor Patient Intake

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Welcome to Grand Island Mental Health & Medical Clinic! (Minor Child Form)

We are excited to get to know you better!

1
Patient's Name* This field is required.
First Name
Middle Name (optional)
Last Name
2
Legal Guardian * This field is required.
First Name
Last Name
3
Legal Guardian's Phone Number* This field is required.
Area Code
Phone Number
4
Patient's Age* This field is required.
5
Patient's Date of Birth* This field is required.
Date
Month
Day
Year
6
Please describe your goals for treatment: * This field is required.(Ex: If treatment was successful in what ways would you be able to tell?)
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Ok
Ok
7
Please describe what factors or events have lead to you seeking treatment at this specific time:* This field is required.
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Ok
8
Please specify the patient's race.
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
9
Please indicate the the current marital status of the patient's parents.* This field is required.Choose all that apply.
Never Married
Divorced
Currently Married
Mother Remarried
Father Remarried
10
Please describe the patient's current relationship with the mother.* This field is required.Choose all that apply.
Good
Mixed
Poor
Never Present
Deceased
11
If the mother is deceased, how long has it been and how old was the patient?* This field is required.Ex: It has been 3 years and the patient was 10 years old.
12
Please describe the patient's current relationship with the father.* This field is required.Choose all that apply.
Good
Mixed
Poor
Never Present
Deceased
13
If the father is deceased, how long has it been and how old was the patient?* This field is required.Ex: It has been 3 years and the patient was 10 years old.
14
Childhood Information* This field is required.Choose all that apply.
Normal home environment
Experienced Abuse
Moved often
Witnessed Abuse
Neglected
Traumatic Events
Did not live with parents
Foster Care
Homelessness
Chaotic Home Environment
Suspected Abuse/Neglect
Victim of Bullying
15
Is there a parenting plan in place?* This field is required.
YESNO
16
If yes, is it being followed by both parents?* This field is required.
YESNO
17
Which parent(s) has medical power for the patient?* This field is required.Choose all that apply.
Mother
Father
Both
18
Which parent(s) has full custody of this patient?* This field is required.
Mother
Father
Both
19
Please explain the custody arrangement. * This field is required.
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Ok
20
Support System* This field is required.Choose all that apply.
Supportive Friends
No or Few Friends
Unsupportive Friends
Substance-use-based Friends
Supportive Family
Unsupportive Family
Distant from Family
Supportive Significant Other
Unsupportive Significant Other
21
Sexual History* This field is required.Choose all that apply.
Homosexual
Bisexual
Heterosexual
22
Social Activities* This field is required.
Enjoy Volunteering
Member of a Church
Attend Church Groups
Attend Summer Camps
23
Does the patient have any children? * This field is required.
YESNO
24
Child Information* This field is required.If the patient has children, please list all children and information.
25
Does the patient have any siblings?* This field is required.
YESNO
26
Sibling Information* This field is required.If the patient has siblings, please list all siblings here.
27
Current Living Arrangements* This field is required.Choose all that apply.
Housing Adequate
Overcrowded
Homeless
Dysfunctional
Dependent on Others for Housing
28
Living Arrangements * This field is required.Please list all persons currently living in the patient's home.
29
Has the patient had any previous mental health treatment?* This field is required.
YESNO
30
Previous Mental Health Treatment History* This field is required.Please list information about all previous mental health treatment.
31
Has the patient had any inpatient treatment?* This field is required.
YESNO
32
Inpatient Treatment History* This field is required.Please list information about all inpatient treatment.
33
Mental Health SymptomsPlease indicate the symptoms the patient is CURRENTLY experiencing and HOW LONG the patient has been experiencing them.
Just recently
In the last year
Several Years
Most of my life
Low energy
Depression
Waking up in the night
Trouble falling asleep
Sleeping too much
Low self-esteem
Self-Harm
Crying often
Feelings of guilt
Feeling worthless
Loss of interest
Withdrawing from others
Anxiety/ Fears
Worries/ Mind racing
Repeating actions
Loss of focus
Hyper- too much energy
Moodiness
Difficulty Concentrating
Anger/Temper Issues
Physical chronic pain
Weight change
Appetite change
Stomach Issues
Frequent headaches
Constipation/Diarrhea
Substance Abuse Issues
Sexual problems
Nightmares
Family Violence
Physical Abuse
Sexual Abuse
Employment Issues
Troubles at School/Daycare
Parent/Child conflict
Relationship Issues
Family conflict
Low energy
Depression
Waking up in the night
Trouble falling asleep
Sleeping too much
Low self-esteem
Self-Harm
Crying often
Feelings of guilt
Feeling worthless
Loss of interest
Withdrawing from others
Anxiety/ Fears
Worries/ Mind racing
Repeating actions
Loss of focus
Hyper- too much energy
Moodiness
Difficulty Concentrating
Anger/Temper Issues
Physical chronic pain
Weight change
Appetite change
Stomach Issues
Frequent headaches
Constipation/Diarrhea
Substance Abuse Issues
Sexual problems
Nightmares
Family Violence
Physical Abuse
Sexual Abuse
Employment Issues
Troubles at School/Daycare
Parent/Child conflict
Relationship Issues
Family conflict
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
Just recently
In the last year
Several Years
Most of my life
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34
Diagnosis History Please indicate if the patient or a family member has been diagnosed with any of the following:
Patient
Parent
Grandparent
Sibling
Child
Depression
Anxiety
ADD/ADHD
PTSD
Autism
Conduct Disorder
Eating Disorders
Schizophrenia
Substance Abuse Disorder
Personality Disorders
Obsessive Compulsive Disorder
Bipolar Disorder
Learning Disorders
Infertility
Depression
Anxiety
ADD/ADHD
PTSD
Autism
Conduct Disorder
Eating Disorders
Schizophrenia
Substance Abuse Disorder
Personality Disorders
Obsessive Compulsive Disorder
Bipolar Disorder
Learning Disorders
Infertility
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
Patient
Parent
Grandparent
Sibling
Child
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35
Suicide Risk Screen* This field is required.If there is currently any suicide risk please seek help and call the National Suicide Hotline at 1-800-273-8255
None
Yes, Recently
Yes, In the past
Suicidal Thoughts?
Suicidal Attempts?
Suicidal Threats?
Suicidal Thoughts?
Suicidal Attempts?
Suicidal Threats?
None
Yes, Recently
Yes, In the past
None
Yes, Recently
Yes, In the past
None
Yes, Recently
Yes, In the past
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36
If you responded "yes" to any of the previous questions please explain the nature of the thoughts, attempts, and/or threats.* This field is required.If you responded "none" to all questions please write n/a.
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37
Does the patient drink or use drugs?* This field is required.
YESNO
38
Has the patient felt he/she should cut down on drinking or drug use? * This field is required.
YESNO
39
Have friends or family annoyed the patient by criticizing his/her drinking or drug use?* This field is required.
YESNO
40
Has the patient ever felt bad or guilty for his/her drinking or drug use?* This field is required.
YESNO
41
Has the patient ever drank or used drugs in the morning to start his/her day?* This field is required.
YESNO
42
Have the patient's relationships with friends or family been negatively influenced by his/her drinking or drug use?* This field is required.
YESNO
43
Please specify the patient's current employment/disability/school status.* This field is required.
Attends School
Employed
Disabled for a Physical Condition
Disabled for a Mental Condition
Disabled for both Physical and Mental Disabilities
Unemployed with no Disability
None of These
44
Current Employer Information* This field is required.
Who is the patient's current employer?
What is the patient's current position at his/her job?
45
How long has the patient been unemployed/disabled?* This field is required.
46
Legal Information* This field is required.Choose all that apply.
No Legal History
Substance Related Charges
Court Ordered Therapy
Felony Charges
Domestic/Assault Charges
Arrested
Jail Time Served
Ran Away from Home
Currently on Parole or Probation
47
How many times has the patient been arrested?* This field is required.
48
How many times has the patient served jail time?* This field is required.
49
How many times has the patient ran away from home?* This field is required.
50
What is the name of the patient's probation officer?* This field is required.
First Name
Last Name
51
Current School Information* This field is required.
Where does the patient currently attend school?
What is the patient's current grade?
Who is the patient's current teacher? (Please list all that apply.)
52
Are there currently any issues at school? * This field is required.
YESNO
53
Please explain the issues currently happening at school.* This field is required.
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Ok
Ok
54
Education Information* This field is required.Please choose all that apply.
Bullying
Being Bullied
Poor Grades
Teacher Conflict
Truancy
Peer Conflict
Learning Disabilities
Special Education
None of These
55
Does the patient attend an Alternative School?* This field is required.
YESNO
56
What is the name of the Alternative School?* This field is required.
57
Has patient ever been suspended, expelled, or retained?* This field is required.
YESNO
58
What is the last grade the patient completed?* This field is required.
59
School History* This field is required.Please list all elementary, middle, and high school the patient has attended.
60
Developmental Milestones* This field is required.
Above Average (ex: walked and talked before most)
Average (ex: walked and talked at same level as peers)
Below Average (ex: walked and talked later than most)
61
Does the patient smoke?* This field is required.
YESNO
62
How much does the patient smoke per day?* This field is required.
63
Has the patient or any family member been diagnosed with any of the following:
Patient
Parent
Child
Grandparent
Diabetes
Head Injury
Thyroid Disease
HIV/AIDS
Stroke
Birth Defects
Cancer
Heart Disease
High Blood Pressure
Alzheimer's/Dementia
Diabetes
Head Injury
Thyroid Disease
HIV/AIDS
Stroke
Birth Defects
Cancer
Heart Disease
High Blood Pressure
Alzheimer's/Dementia
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
Patient
Parent
Child
Grandparent
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64
Is the patient currently taking any medications?* This field is required.
YESNO
65
Medication List* This field is required.Please list any and all medications the patient is currently taking including over the counter medications
66
Is the patient allergic to any medications?* This field is required.
YESNO
67
Please list all allergies and reactions.* This field is required.
68
* This field is required.(You can ask for a copy of these Terms, Conditions, and Client Rights and Responsibilities at any time)
69
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