Please provide the following information for the child or adolescent:
Medical Insurance Information
Family Information
Please list ALL individuals living in the child’s household:
NameAgeRelarionshipKnown to child asOccupation
Example:Jane Dow52Grandmother"Mommy"homemaker
Please list all OTHER family/caregivers NOT currently residing with the patient (this would include biological parents, step parents, siblings, step siblings, etc.)
NameAgeRelarionshipKnown to child asOccupation
Example: Ashley Smith30Biological Mother"Mama Ashley"Sales
Past Psychiatric History
If your child has had prior counseling, psychiatric care, psychiatric hospitalizations, or testing place list:
Inpatient Psychiatric Hospital Treatment Phone # Dates Seen Reason for Treatment
Outpatient Doctor / Counselor NamePhone # Dates Seen Reason for Treatment
Development Milestones (answer as best as you can):
Problem List
Check any boxes that apply to your child
Current / Past
Current / Past
Please note if your child has ever taken any of the following medications:
Medication / Dose Beneficial Effects Side EffectsDurationReason Stopped Dosage
Example: Abilify -20 mg at bedtime Helps him to not hear voices Headaches 7/03 - Present Didn’t work 2.5 ml
Abilify / Abilify discmelt / Abilify injection (aripiprazole)
Adderall / Adderall XR (amphetamine salts)
BuSpar (buspirone)
Benadryl (diphenhydramine)
Catapres (clonidine) tablets / patches
Celexa (citalopram)
Concerta (methylphenidate)
Cymbalta (Duloxetine)
DDAVP (desmopresin)
Daytrana Patch ( Methylphenidate)
Depakote / Depakote ER (divalproex sodium)
Desyrel (trazodone)
Dexedrine, Dextrostat (dextroamphetamine)
Focalin (dexmethylphenidate)
Geodon (ziprasidone)
Intuniv (guanfacine)
Klonopin (clonazepam)
Lamictal (lamotrigine)
Lexapro (escitalopram)
Lithobid, Lithonate, Lithotabs (lithium)
Metadate ER (methylphenidate)
Methylin / Methylin ER (methylphenidate)
Prozac (fluoxetine) / Prozac weekly
Remeron / Remeron Soltab (mirtazapine)
Risperdal (risperidone)
Ritalin / Ritalin LA (methylphenidate)
Seroquel / Seroquel XR (quetiapine)
Strattera (atomoxetine)
Tegretol (carbamazepine)
Tenex (guanfacine)
Trileptal (dibenzazepine)
Topamax (topiramate)
Vistaril, Atarax (hydroxyzine)
Vyvanse (lisdexamfetamine)
Wellbutrin SR / Wellbutrin XL (bupropion)
Xanax / Xanax XR (alprazolam)
Zoloft (sertraline)
Zyprexa / Zyprexa Zydis / Zyprexa IM
Medical History
Has your child ever had any of the following? If so, please list dates of problems/procedures.
List any current health problems and child’s age when diagnosed (Ex: Asthma, Diabetes, etc.):
Current Health Problem Age when diagnosed
List any past health problems and age when they occurred:
Past Health Problem Age when ocurred
List any current medications and the doctor who prescribes them:
Current Medications Dr. Name
Legal/Agency Information
Has this child been the victim of:
Educational History
Please bring copies of testing / IEP / 504 plan if available.