Child Psychiatric Intake

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All information on this form is strictly confidential.
Please complete the following form to help us understand your child. This will decrease the time needed to make an accurate evaluation of your child’s needs. Please bring it to the first visit. Thank you!

Child’s Name*

Age

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Form Completed By

How are you related to the child?

Whose idea was it to bring child to clinic?

What are your current concerns regarding your child and what problem(s) you are seeking help for?

At what age was the problem first noted?

Why do you think your child is having problems?

Describe how child’s problems affect you, other family members, others

What would you or referring person like to see done for your child?

What, if anything, happened recently to make the problem(s) worse?

Please review the following list and circle what you feel fit your child

Sad/depressed

Cries frequently

Worries a lot

Suicidal Thoughts

Sleeping Problems

Lacks guilt/remorse

Difficulty making friends

Difficulty keeping friends

Little interest in friends

Little interest in activities

Disrespectful

Argues

Seems angry

Ignores rules

Defies authority

Temper tantrums

Not completing schoolwork

Acts before thinking

Short attention-span

Unable to sit still

Overactive

Underactive

Self-Injurious Behavior

Hurts animals

Sets fires

Steals

Lies a lot

Too serious

Clowns a lot

Acts spoiled

In own world

Afraid/fearful

Accident-prone

Seems insecure

Mentally slow

Interested in sex

Looks “high” often

Separation problems

Imaginary friends

Family Problems

School Problems

Motor/Vocal Tics

Bullying/Teasing

Aggressive

Fights a lot

Food Issues

Has he/she ever had treatment for this problem?

Yes

If so, Where?

When?

Check if yes

Has your child ever been a patient of a psychiatrist?

Has your child ever been in talk therapy, play therapy or family therapy?

Has your child ever attempted suicide?

Has your child ever been hospitalized for any psychiatric reason?

Has your child ever taken any psychiatric medication?

If yes, what was his/her diagnosis and how long was he/she treated?

If yes, with whom, when and for how long?

If yes, name the hospital(s), the date(s), and for what reason?

If yes, which ones? (see examples below)

Medication Taken and Dosage

If yes, which ones? (see examples below)

Response/Side-Effects and Reason Discontinued

Some examples of PSYCHIATRIC MEDICATIONS are:

Antidepressants
Celexa (citalopram) Luvox (fluvoxamine) Pristiq (duloxetine)	Prozac (fluoxetine) Effexor (venlafaxine) Elavil (amitriptyline)	Zoloft (sertraline) Cymbalta (duloxetine) Anafranil (clomipramine)	Paxil (paroxetine) Wellbutrin (bupropion) Pamelor (nortrptyline)	Lexapro (escitalopram) Remeron (mirtazapine) Tofranil (imipramine)
Mood Stabilizers
Depakote (valproate)	Lamictal (lamotrigine)	Tegretol (carbamazepine)	Topamax (topiramate)	Lithium
Antipsychotics/Mood Stabilizers
Seroquel (quetiapine) Prolixin (fluphenazine)	Zyprexa (olanzepine) Clozaril (clozapine)	Geodon (ziprasidone) Risperdal (risperidone)	Abilify (aripiprazole) Fanapt (iloperidone)	Haldol (haloperidol) Latuda (lurasidone)
Sedative/Hypnotics
Ambien (zolpidem)	Lunesta (eszopiclone)	Sonata (zaleplon)	Rozerem (ramelteon)	Restoril (temazepam)
Antianxiety medications
Xanax (alprazolam)	Ativan (lorazepam)	Klonopin (clonazepam)	Valium (diazepam)	Buspar (buspirone)
ADHD medications
Adderall (amphetamine)	Concerta (methylphenidate)	Ritalin (methylphenidate)	Strattera (atomoxetine)	Vyvanse (lisdexamfetamine)
Others
Provigil (modafinil)	Desyrel (trazodone)	Emsam (selegiline)	Savella (milnacipran)	Symbyax (fluoxetine/olanzapine)

Family Psychiatric History:

Has anyone in your family been diagnosed with or treated for:

Check if yes

Depression

Bipolar or Manic-Depressive disorder

Anxiety

ADHD

Schizophrenia

Alcohol abuse

Other substance abuse

Suicide attempt

Depression - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Bipolar or Manic-Depressive disorder - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Anxiety - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

ADHD - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Schizophrenia - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Alcohol abuse - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Other substance abuse - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Suicide attempt - Who? (mother/ father/ children / siblings/ grandparents/aunts/uncles/cousins)

Medical History

Primary Care Provider Name

Address

Phone

How long has your child been a patient with this provider?

Date of last appointment

MM slash DD slash YYYY

Are immunizations up to date?

Current Weight

Height

Has child had serious illnesses, injuries, surgeries, hospitalizations?

List any medications your child is currently taking (name of medication and dosage)

List any food or medication allergies:

Pharmacy

Phone

DEVELOPMENTAL HISTORY

Was the pregnancy with this child desired?

Length of pregnancy

Problems during pregnancy (include alcohol/drug usage by mother)

Complications during delivery

Explain if mother/child separated after birth

Other parent/child separations

Describe child as an infant/toddler (cheerful, fussy, cuddly, withdrawn)

Age child first sat up

Took steps

Spoke words

Age first spoke in sentences

weaned

Fed him/herself

Age toilet-trained during day

Night

Problem now?

Age dressed self

Tied shoe-laces

Rode 2-wheel bike

Age his voice changed (adolescent males)

Developed body hair

Age 1st menstruation (adolescent female)

Breast development

Social Information and Family Background:

UntitledWhere was the child born?

Where has he/she lived?

Child was raised by

Who lives in child’s main household?

Child’s parents

Father

Age

Mother

Age

Step-Parent

Age

What is the father’s occupation?

What is the mother’s occupation?

List Child’s Brothers and Sisters and age (including half brothers and sisters and step brothers and sisters. If any of the the child’s siblings are deceased, put down the name and the year of death in the Age column)

Name - Age

Parent/child relationship

How do you and spouse/partner show affection to child?

If one of child’s biological parents is out of the home, describe his/her relationship with child

Responsibilities/rules

How does child handle these?

Has child threatened/attempted to run away or stayed out all night?

Explain

What do you and your spouse/partner DO when your child misbehaves? - You

You

What do you and your spouse/partner DO when your child misbehaves? - Spouse/partner

Spouse/partner

How do you and spouse/partner feel about using PHYSICAL DISCIPLINE? - You

You

How do you and spouse/partner feel about using PHYSICAL DISCIPLINE? - Spouse/partner

Spouse/partner

Has family ever been involved with Protective Services?

Yes

When?

Reason

Describe any BEHAVIOR of yourself, partner, or other adults in the home (drinking, drugs, verbal or physical conflict, suicide attempts, etc.) that may have affected your child

Describe any EVENTS--family illness, death, separation, divorce, move to a different neighborhood or school, change in family finances, etc.-- that may have affected your child

Employment/training/work hours of each parent/guardian: You

You

Employment/training/work hours of each parent/guardian: Spouse/partner

Spouse/partner

ETHNIC/CULTURAL background of child

RELIGIOUS/SPIRITUAL background

LEGAL problems of child (past and present)

SCHOOL

Grade

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone

Teacher

Counselor

In special classes?

If so, since what grade?

Learning disabilities?

Has child repeated any grades?

Which grades?

Describe attendance

Describe effort/attitude toward school

Describe academic performance

Describe behavior in school

When did school performance/behavior change?

Why do you think it changed?

Education of each parent/guardian

Is there anything else that you would like New Dimension Group to know?

Signature

Date

MM slash DD slash YYYY

Emergency Contact

Telephone #

Child Intake Form