Patient Legal Name
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Date of Birth
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Grade & School
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Email
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Patient Address
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Patient Cell Phone Number
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Parent #1 Name, Address, Phone Number
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Parent #2 Name, Address, Phone Number & Email
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Preferred Phone Number
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If divorce or separated, please include a description of the custody arrangement and the divorce decree regarding medical services.
If someone else, please provide their name, address, phone number and e-mail address, and describe their relationship to the patient.
Psychiatric History
Does the patient have a previous psychiatric or learning difference diagnosis?
If so, when was the diagnosis made and by whom? Please elaborate.
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Has the patient had previous psychoeducational testing or neurophysical testing?
If so, when?
Has the patient ever been treated by a psychiatrist in the past? If so, please give type of treatment as well as start and end date.
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Has the patient ever had individual psychotherapy? If yes, when and with whom?
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Has the patient ever attended group/family therapy? If yes, when and with whom?
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Current Medications
Include name of ALL medication, supplements, dosage, reason is was prescribed, who prescribed it and if there were any side effects.
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Past Psychiatric Medications
Include name of ALL medication, dosage, reason it was prescribed, who prescribed it, when it was taken and if there were any side effects.
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Does the patient currently use any substances or have a history of substance abuse? Has the patient ever received treatment for substance abuse?
Please list any substances, when they were used and the date of the last use.
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Does the patient have a history of trauma?
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When did the patient's symptoms begin? Did something occur to precipitate them?
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Have there been any symptom-free periods? If yes, when and for how long?
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Has the patient ever been psychiatrically hospitalized? If yes, when, how and under what circumstances?
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Has the patient attended Day Hospital or an Intensive Outpatient Program?
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Has the patient ever hurt him or herself in any way (e.g. cutting or burning)? If yes, when, how and under what circumstances?
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Has the patient ever thought of or attempted to commit suicide? If yes, when, how and under what circumstances?
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If you are human, leave this field blank.