Pediatric Psychiatric Intake Form – Patient/Parent GENERAL INFORMATION Patient Name:_________________________________________ Date of Birth:_________________ Person completing form:________________________________ Relation to patient:____________ Please describe the reason for visit and/or current concerns:

RISK ASSESSMENT Has your child ever attempted suicide? Yes No Has your child ever harmed themselves by cutting, burning, etc.? Yes No

Has your child recently engaged in risk-taking behavior? (Check all that apply) Alcohol/Drug use Gang involvement Unprotected Sex Drug dealing Shoplifting Trading sex for money, drugs, or possessions Reckless driving Carrying/using a weapon Other: ___________________________________________________________________________

Do you feel that you live in a safe place? Yes No Are there guns in your home? Yes No If yes, are the guns locked up? Yes No Has your child ever witnessed violence in the home? Yes No

LEGAL INVOLVEMENT Yes No Yes No Yes No

Has your child ever been on probation? Has your child ever received child protection services? Has your child had any other involvement with the legal system? If yes to any of the above, please explain:

MENTAL HEALTH HISTORY Please check all current and previous mental health care Provide details (e.g. where, number of times, provider or therapist name, caseworker, etc.) Partial Hospitalization Detail: _____________________________________________ Intensive Outpatient Detail: _____________________________________________ Residential Treatment Detail: _____________________________________________ Day Treatment Detail: _____________________________________________ Psychiatric Care Detail: _____________________________________________ Outpatient Therapy Detail: _____________________________________________ Substance Abuse Treatment Detail: _____________________________________________ Detox Detail: _____________________________________________ Case Management Detail: _____________________________________________ In-home skills/family therapy Detail: _____________________________________________ Other:

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PAST PSYCHOTROPIC MEDICATION HISTORY Antidepressants Prozac (Fluoxetine) Zoloft (Sertraline) Luvox (Fluvoxamine) Paxil (Paroxetine) Celexa (Citalopram) Lexapro (Escitalopram) Effexor (Venlafaxine) Pristiq (Desvenlafaxine) Cymbalta (Duloxetine) Wellbutrin (Bupropion) Desyrel (Trazodone) Remeron (Mirtazapine) Serzone (Nefazodone) Anafranil (Clomipramine) Pamelor (Nortriptyline) Viibryd (Vilazodone) Elavil (Amitriptyline) Tofranil (imipramine) Other: __________________

Mood Stabilizers Tegretol (Carbamazepine) Lithium Depakote (Valproate) Lamictal (Lamotrigine) Trileptal (Oxcarbazepine) Other: __________________

Neuroleptics / Antipsychotics Risperdal (Risperidone) Seroquel (Quetiapine) Zyprexa (Olanzepine) Geodon (Ziprasidone) Abilify (Ariprprazole) Clozaril (Clozapine) Haldol (Haloperidol) Prolizin (Fluphenazine) Other: __________________

Anti-Hypertensives / Anti-Anxiety Catapres (Clonidine Tenex (Guanfacine) Intuniv (Guanfacine XR) Inderal (Propanolol) Atenolol (Tenormin) Other: _________________

Benzodiazepines / Sedatives Xanax (Alprazolam) Ativan (Lorazepam) Restoril (Temazepam) Klonopin (Clonazepam) Valium (Diazepam) Ambien (Zolpidem) Buspar (Buspirone) Other: __________________

Stimulants Adderall (amphetamine) Vyvanse (Dexamphetamine) Concerta (Methylphenidate) Ritalin LA (Methylphenidate) Daytrana (Methylphenidate) Metadate (Methylphenidate) Focalin (Dexmethylphenidate) Strattera (Atomoxetine) Other: __________________

Sleep Aids Melatonin Desyrel (Trazodone) Remeron (Mirtazapine) Ambien (zolpidem) Lunesta (Eszopiclone) Unisom (Doxylamine) Benadryl (Diphenhydramine) Rozerem (Ramelteon) Sonata (Zaleplon)

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CURRENT MEDICAL CONCERNS Head Gastrointestinal Constitutional

Concussion Heartburn/reflux Weight loss Head injury Nausea/vomiting Fatigue Headaches Constipation Fever Migraines Change in bowel movements Other: _____________ Traumatic Brain Injury Jaundice Other: _____________ Abdominal Pain Neurological

Black or bloody bowel movement Loss of strength Eyes Other: _____________ Numbness

Needs glasses/contacts Headaches Eye pain Genitourinary Tremors Double vision Burning/frequency Memory Loss Decreased vision Bedwetting Tourette’s Syndrome Other: _____________ Blood in urine Seizures

Erectile dysfunction Other: _____________ Ears, Nose, Throat Abnormal discharge

Difficulty hearing Bladder leakage Endocrinological Ringing in ears Menstruation Unexplained weight loss Vertigo Other: _____________ Weight gain Difficulty swallowing Hot/cold intolerance Pain Musculoskeletal Diabetes Other: _____________ Hypothyroidism

Other: _____________ Cardiovascular

Murmur Chronic Illness Chest pain Asthma Palpitations Diabetes Dizziness Skin Other: _____________ Fainting Spells Shortness of breath Sensory concerns Difficulty lying flat Sound/noises Swelling Ankles Touch/tactile Other: _____________ Oral/Textures

Joint pain/swelling Stiffness Muscle pain Back pain Other: _____________

Hair loss Rash/hives Lesions/sores Itching/burning Easy bruising Other: _____________ Clothing/Tactile

Respiratory Other: _____________ Cough illness Pain Shortness of breath Use of inhaler use of oxygen Other: _____________

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YOUR CHILD’S DEVELOPMENT How long was the pregnancy? ______ Weeks Unknown

Check any concerns or complications that occurred during the pregnancy” No or Poor prenatal care Preterm labor Tobacco use Preeclampsia Serious infection or illness Alcohol use Gestational Diabetes Significant stress or trauma Drug use Unknown Other: _____________________________________________

Vaginal Cesarean Unknown Yes No Unknown Yes No Unknown Yes No Unknown

Yes No Unknown

How was your child delivered? Was your child’s delivery induced? Was your child’s delivery an emergency? Did your child come home within 2 days of delivery? Were there any complications during labor or the delivery of your child?If yes, Please explain:

Check if any of the following were concerns regarding your child’s development Social skills/interacting with others Calming Speech Play Tantrums Vision Activity level Language Hearing Gross motor skills (running, moving, crawling Fine Motor skills (eating, writing, buttoning a shirt)

Did your child experience any major delays in these areas? (check all that apply) Speech Toilet training Sitting, crawling, or walking Sleeping through the night Other: ___________________________________________________________________________

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FAMILY MENTAL HEALTH HISTORY Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________ Who:____________________________________

Suicide attempt Suicide completed Schizophrenia Bipolar Disorder Depression Anxiety ADHD Autism Spectrum Disorder Alcoholism Drug addiction Other addictive behaviors Other: ______________________________

Who:____________________________________

SOCIAL HISTORY Who does your child live with? (check all that apply)

Describe your child’s biological parents current relationship (check all that apply)

Father Never married, living together Mother Never married, living apart Step parent(s) Married Sibling(s) Separated Grandparent(s) Divorced Foster Care Biological mother remarried Group home Biological father remarried Homeless Widowed Shelter Other: _____________________ Other: ____________________

Please describe any court ordered custody arrangements regarding your child: (Please also bring a copy of the custody agreement for the chart)

Is your child adopted? Yes No If yes, at what age? __________________

SUPPORT SYSTEM Please describe your child’s religion/spiritual beliefs: __________________________________________ ____________________________________________________________________________________

Who is most supportive to your child? (check all that apply) Father Mother Step Parent(s) Sibling(s) Grandparent(s) Teacher(s) Friend(s) Pastor/Spiritual leader Other: _____________________________

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EDUCATION HISTORY Current School: _________________________________ Grade: ___________________

Has your child experienced any difficulties with: Reading Writing Arithmetic Other: ________________________________

Has your child received special education services (IEP)? Yes No Has your child received a 504 plan? Yes No

EMPLOYMENT What is your child’s employment status? (check one) Employed full-time Employed part-time Not employed and NOT seeking employment Not employed and seeking employment If employed, where does your child work? _______________________________________________

What is your employment status? (check one) Employed full-time Employed part-time Not employed and NOT seeking employment Not employed and seeking employment If employed, what is your occupation? _______________________________________________

What is the employment status of your child’s other parent/guardian? (check one) Employed full-time Employed part-time Not employed and NOT seeking employment Not employed and seeking employment If employed, what is your occupation? _______________________________________________

STRENGTHS AND ACTIVITIES

List three of your child’s strengths special gifts, and/or talents: 1. ________________________________________________________2. ________________________________________________________3. ________________________________________________________

List three activities or hobbies that your child enjoys: 1. ________________________________________________________2. ________________________________________________________3. ________________________________________________________

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