New Patient Minor Intake

1
Name* This field is required.
First Name
Middle Name (optional)
Last Name
2
Sex* This field is required.
Male
Female
N/A
3
Date of Birth* This field is required.
Month
Day
Year
4
Contact Number:
Area Code
Phone Number
5
How would you prefer to receive appointment reminders?
Automated Phone Call
Text Message
No Appointment Reminder Needed
If there is another parent or responsible party you would like to receive appointment reminders please list their phone number here:
6
Where did you hear about us
Online Search (ex: Google)
Social Media (ex:Facebook)
Friend
Doctor or Medical Group
7
Child's Primary Address:* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
8
Emergency Contact:* This field is required.
First Name
Last Name
9
Relationship with Emergency Contact
10
Emergency Contact Phone Number* This field is required.
Area Code
Phone Number
11
Is this child covered by insurance?* This field is required.
YESNO
12
Insurance Information(Child will not be able to be seen without providing insurance card at time of first appointment)
Name of Insurance Company
Insurance ID Number
Group ID Number (if applicable)
13
To whom should we send a bill if necessary?* This field is required.
To myself at the address listed
To someone other than myself
14
Name of Person Responsible for Payment* This field is required.
First Name
Last Name
15
Address Of Person Responsible for Payment
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
16
Phone Number of Person Responsible for Payment
Area Code
Phone Number
17
Please describe your goals for treatment: * This field is required.(Ex: If treatment was successful in what ways would you be able to tell?)
Huge
Large
Normal
Small
Ok
Ok
18
Please describe what factors or events have lead to you seeking treatment at this specific time:* This field is required.
Huge
Large
Normal
Small
Ok
Ok
19
Parent/Guardian Information* This field is required.
Biological Mother's Name
Occupation
Biological Father's Name
Occupation
Other Legal Guardian: (if applicable)
Relationship
20
Parental Information* This field is required.
Never Married
Divorced
Currently Married
Mother Remarried
Father Remarried
Please indicate the current marital status of child's parents (check all that apply)
Good
Mixed
Poor
Deceased
Never Present
How is child's current relationship with mother? (check all that apply)
Good
Mixed
Poor
Deceased
Never Present
How is child's current relationship with father? (check all that apply)
Please describe any current issues with siblings:
21
Environment* This field is required.
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
22
Social Questionnaire* This field is required.Please choose any that apply to you
Supportive Friends
No or Few Friends
Supportive Family
Unsupportive Friends/ Negative Peer Group
Unsupportive Family
Inconsistent Care Givers
Lack of Family Resources
Distant from family
Homosexual
Bisexual
Heterosexual
Enjoy Volunteering
Member of a church
Attend Church Groups
Attend Support Groups
Attend summer or day camps
Head Start
Mentoring Program (ex: Big Brothers Big Sisters or Teammates)
23
Sibling Information
24
Configurable list* This field is required.Please list all persons living in the household and their relationship with the child
25
Has this child had any previous mental health treatment?* This field is required.
YESNO
26
Previous Treatment History
Yes
No
Previous counseling or medication management?
Name of therapist or clinic
Yes
No
Inpatient treatment?
Name of facility
How long ago was inpatient treatment?
27
Mental Health SymptomsPlease indicate the symptoms you are CURRENTLY experiencing and HOW LONG you have experienced 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
1 of 37
28
Diagnosis History Please indicate if you or a family member has been diagnosed with any of the following:
Myself
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
Depression
Anxiety
ADD/ADHD
PTSD
Autism
Conduct Disorder
Eating Disorders
Schizophrenia
Substance Abuse Disorder
Personality Disorders
Obsessive Compulsive Disorder
Bipolar Disorder
Learning Disorders
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
Myself
Parent
Grandparent
Sibling
Child
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29
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
1 of 3
30
Are there any concerns of drinking or drug use?* This field is required.
YESNO
31
Legal Information
No Legal History
Substance related charges
Assault Charges
Court ordered therapy
Felony charges
Arrested
Jail time served
Currently on parole or probation
Please choose all that apply
32
Education Information
Name of High School
Current Grade:
Name of Elementary School
Name of College Attending
33
Name of Primary Care Physician
First Name
Last Name
34
Please list any complications of pregnancy or delivery
35
Please list any medical concerns
36
Were developmental milestones met on time?* This field is required.(ex: walking and talking at appropriate times?)
YESNO
37
Has this child or any family members been diagnosed with any of the following:
Myself
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
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
Myself
Parent
Child
Grandparent
1 of 10
38
Is the child taking any medications, currently?* This field is required.
Yes
No
39
Medication ListPlease list any and all medication you are currently taking including over the counter medications
40
Any allergies to medications?
YESNO
41
Please list all allergies and reactions
42
Would you like information pertaining to our office Infectious Control Program or Service Definitions?If yes, this information will be given to you at the time of your first appointment
YESNO
43
* This field is required.(You can ask for a copy of these Terms, Conditions, and Client Rights and Responsibilities at any time)
44
The easiest way to get information quickly is by "liking" and checking our Facebook page for holiday and weather related closings and office updates
45
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