New Patient Form – Child & Adolescent Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstMiddleLastPreferred NameGender *MaleFemale*Other*If Other please specify*OtherDate of Birth (MM/DD/YYYY) *Address *City *State *Zip Code *Parent's Name *FirstLastParent's Phone *Home PhoneParent's Primary Email *Parent's Secondary EmailParents areMarriedSingleDivorcedWidow/ WidowerSeperated*If Divorced, Please specify the Custody ArrangementsFamily Members Living at HomeFatherMotherBrother(s)Sister(s)OthersEmergency Contact : Name *FirstLastEmergency Contact : Phone *Child's School GradeGuarantor's Name *FirstLastGuarantor's Birthdate (MM/DD/YYYY) *Guarantor's Address *Guarantor's City *Guarantor's State *Guarantor's Zip Code *Guarantor's Cell Phone Number *Guarantor's Alternate PhoneGuarantor's Email *Subscriber (Primary on Insurance) *Patient's Relation with Subscriber (Primary on Insurance) *ParentGrand Parent*Others*If Others please specify*OthersInsurance Company Name *Insurance Company Address *Insurance Company City *Insurance Company State *Insurance Company Zip Code *Insurance Company Phone *Insurance Holder's ID Number *Insurance Holder's Group NumberDoes the Insured have a Secondary Insurance YesNoIf No, please skip the secondary insurance section.Secondary Insurance Company NameSecondary Insurance Company AddressSecondary Insurance Company CitySecondary Insurance Company StateSecondary Insurance Company Zip CodeSecondary Insurance Company Phone numberSecondary Insurance Holder's ID NumberSecondary Insurance Holder's Group NumberCurrent Pharmacy *Pharmacy's Address *Pharmacy's Zip Code *Pharmacy's Phone Number *Visit Information: Referred by:Principal Reason(s) for Requesting a Treatment/Consultation *Area of Concern (Academic/Work)Difficulty with peersDifficulty with authorityBehavioral problemsLearning disabilityDifficulty with focus and concentrationLanguage / speech delayHistory of current academic/work problemsAreas of Concern (Personal)Unduly sadOverly anxiousTemper tantrumsWithdrawn / shyUncontrollable habits / mannerismStrange/bizzare behaviourSelf harmSuicidal thoughts/ behaviourHomicidal though /behaviourPerceptual/visual disturbanceProblem with self care(eating, bathing , toileting)Risk taking behaviourAreas of Concern (family)Parent child problemMarital conflict or co-parenting problemsSibling conflictRecent family changes *(elaborate)Recent trauma/loss *(elaborate)Domestic violence/abuse *(elaborate)*Elaborate (Family changes/trauma/loss/violence/abuse)Current Medical Illnesses *Enter NA if none.Prior Psychiatric Diagnosis/TreatmentMedication Allergies and Reactions *Enter NA if none.Prior/Current Primary Care PhysicianPrior/Current Primary Care Therapist Prior/Current Mental Health Provider PsychiatristPast Treatment HistoryPartial HospitalisationIntensive Out patient ProgramsHospitalisationNoneMonth/Year and Reason for HospitalizationHas the Patient Ever had Psychological Testing? YesNoIf yes, then please email test results to [email protected]Family Psychiatric HistoryList Past/Current Psychiatric Medications Including Maximum Dosages and FrequencySubmit
