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Potential Patient Information

Today's Date

Name

Date of Birth

Age

Parent/Guardian Name

Relationship

Address

City

State

Zip Code

Parent/Guardian Phone

Parent/Guardian Email

Insurance Information

Name of Insurance

Insurance ID Number

Policy Holder Name

Policy Holder DOB

Living Arrangements Post-Discharge

Where is the patient currently located/placed?

Current City

Current State

Medical Information

Previous Diagnosis

Current Behaviors/Symptoms: Current Behaviors/Symptoms: Current and past behaviors (specify when/how often they are an issue. Please include dates and timeframes of concerning behaviors

Current/Past Medical Issues/include Allergies. Please include height and weight of patient

Family Medical/Mental Health History

Currently prescribed medicine?

Yes

Substance Abuse History

Alcohol

Age first used

Amount/Frequency

Route

Last used

Cannabis

Age first used

Amount/Frequency

Route

Last used

Hallucinogenic ("Shrooms," Acid, LSD, etc.)

Age first used

Amount/Frequency

Route

Last used

Cocaine

Age first used

Amount/Frequency

Route

Last used

Methamphetamine

Age first used

Amount/Frequency

Route

Last used

Opiates

Name of Opiate

Age first used

Amount/Frequency

Route

Last used

Inhalants

Age first used

Amount/Frequency

Route

Last used

Other (ecstasy, molly, spice, Xanax, triple C's, sleeping pills, etc.)

Name of Drug

Age first used

Amount/Frequency

Route

Last used

Legal

Does the child have any current legal involvement with the judicial system?

Yes

Is the child currently in state custody?

Yes

High Risk Behaviors

(please provide a description of behaviors as well as a time line for behaviors)

Aggression/Violence

Property/Destruction

Runaway Behaviors

Self-Harm Behaviors

Problem Sexual Behavior

History of Suicidal Behaviors

History of Homicidal Behaviors

Psychosis (hallucinations/delusions)

Ingesting/Swallowing Foreign Objects

Eating Disorder History

Other Behaviors of Concern

Developmental/Educational

Current Grade/School

Has patient had to repeat a grade?

Special Education

Academic Achievement/Failure

Suspensions/Expulsions

Developmental Disabilities/Full Scale IQ

Misc.

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