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New Patient Form Additional Information (child and adolescent)

Please fill the form to the best of your knowledge to help us better prepare for your appointment.

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Name
Did your child currently or in the past receive:
Does your child receive
Does your child have problems with
Areas of Concern (Check all that apply, Personal/Social Adjustment)
Areas of Concern (Check all that apply, School Adjustment):
Areas of Concern (Check all that apply, Family Adjustment):
Areas of Concern (Check all that apply, Physical/Developmental Factors):
Has child ever been a victim of abuse or neglect?
Are you concerned that your child is using (or has used) drugs or alcohol?
Are you concerned about child’s sexual activity?
Is your child currently seeing a therapist?
If yes, please provide contact information and include name in release of info form
Please review the following list of medications and if they have taken it:

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