Irp-cdn.multiscreensite.com



Child Psychiatry Intake Form Name:____________________________________________Date of Birth:__________________________Person completing the form: __________________________________________Please complete this form to provide valuable information in advance of your child’s appointment. This information allows for more time to be spent in discussion, counseling on treatment options and coordination of care. If there is a specific question that you prefer to discuss in person rather than complete on the form please note it with a star and write “discuss in person”. What is(are) the reason(s) your child is scheduled for an appointment?________________________________________________________________________________________________________________________________________________________________________Current Medications: List all medications, supplements, herbals, over-the-counter medications, treatments. **For mental health medications please make notes on the current dose, how long you have been on the medication, if you forget or are unable to take the medication more than twice per month, side effects that you have from the medication, if you feel the medication is helpful or not and any additional information you have. Current MedicationsPrescribed MedicationsSizeDoseFrequencyPrescriber/Side EffectsLipitor(example)40mg1 tabletOnce a dayDr. Med Hills/drowsinessPast Medications:List all past medications you have used. It is helpful if you can include information on when you took it, for how long you were on it, the dose, side effects, if it worked or not and why you stopped it.Below is a list of some more common mental health medications. You can circle any that you know you took, cross out any that you know you did not take and neither circle it nor cross it off if you are not sure. The generic name is listed with the brand name(s) in parentheses. If you have never taken a psychiatric medication you can write “none” in the space below and skip the list. desipramine (Norpramin)amitriptyline (Elavil)nortriptyline (Aventyl, Pamelor)nefazodonefluoxetine (Prozac, Sarafem)bupropion (Wellbutrin)sertraline (Zoloft) paroxetine (Paxil)venlafaxine (Effexor)desvenlafaxine (Pristiq)fluvoxamine (Luvox)mirtazapine (Remeron)citalopram (Celexa)escitalopram (Lexapro)duloxetine (Cymbalta)vilazodone (Viibryd)vortioxetine (Trintellix)levomilnacipran (Fetzima)phenelzine (Nardil)tranylcypromine (Parnate)selegiline (Emsam patch)lithium (Eskaltih, Lithonate)carbamazepine (Tegretol, Equetro)divalproex (Depakote)lamotrigine (Lamictal)oxcarbazepine (Trileptal)methylphenidate (Ritalin, Concerta, Metadate, Methylin, Daytrana patch, Quilivant XR liquid, Jornay PM)dexmethylphenidate (Focalin, Dexedrine)lisdexamphetamine (Vyvanse)d- and l- amphetamine (Adderall)modafinil (Provigil, Sparlon)armodafinil (Nuvigil)amphetamine salts (Mydayis, Evekeo)amphetamine sulfate (Adzenys)atomoxetine (Strattera)clonidine (Catapres, Kapvay)guanfacine (Tenex, Intuniv)chlorpromazine (Thorazine)clozapine (Clozaril)quetiapine (Seroquel)perphenazine (Trilafon)haloperidol (Haldol)risperidone (Risperdal)paliperidone (Invega)olanzapine (Zyprexa)ziprasidone (Geodon)iloperidone (Fanapt)asenapine (Saphris)lurasidone (Latuda)aripiprazole (Abilify)brexpiprazole (Rexulti)cariprazine (Vraylar)diazepam (Valium)chlordiazepoxide (Librium)clonazepam (Klonopin)lorazepam (Ativan)alprazolam (Xanax)buspirone (BuSpar)gabapentin (Neurontin)hydroxyzine (Atarax, Vistaril)propranolol (Inderal)atenolol (Tenormin)guanfacine (Tenex, Intuniv)clonidine (Catapres, Kapvay)pregabalin (Lyrica)prazosin (Minipress)clomipramine (Anafranil)temazepam (Restoril)triazolam (Halcion)zolpidem (Ambien, Intermezzo)zaleplon (Sonata)eszopiclone (Lunesta)ramelteon (Rozerem)doxepin (Silenor)suvorexant (Belsomra)Is your child currently seeing a counselor/therapist? If so please list the person’s name, contact information, how long you have been working together and how often the child goes. ________________________________________________________________________________________________________________________________________________________________________Symptoms:Please review and answer each of the items below. For the items with a box to the left, mark the box according to how your child reports feeling or what you observe. Place an “N” for never having experienced it, a “P” for having experienced it in the past and a “C” for currently experiencing it. You can place a star next to ones that are most significant. N = neverP = PastC = Currentdepression poor interestpoor motivation increased appetitedecreased appetitedisrupted sleepsleeping too muchlow energy / fatiguedhaving poor self esteemfeeling worthlessfeeling guiltypoor concentration indecisivehaving a very high self esteemsleep <5 hours/night and not feeling tiredexcessively talkativeracing thoughtsbeyond average risk takinganxious / worriedunable to control anxietyrestless, keyed up, on edgeirritablephysical anxiety (muscle tension, nausea / vomiting, fast heart rate, palpitations, chest pain, shortness of breath, headaches, dizzy, chills, generally feel sickabrupt surges of intense fear/discomfort/anxietyfear of a panic attack happeninghallucinations (seeing, hearing, feeling, smelling, tasting something other people don’t experience)paranoidhistory of traumaintrusive thoughts related to traumaflashbacks to traumaavoidance of things related to the traumaincreased startle responsecareless work mistakespoor attention when trying to pay attention not listening when spoken tonot able to follow instructionsmuch below average organization despite effortexcessively losing thingsunable to stay seated or still for 5 minutesinappropriately interrupting othersrecurrent thoughts / urges / images that are not controllable repetitive behaviors related to urges that cannot be controlled excessively intense ritual behaviorsrestriction in foot intake results in hunger and excess weight lossintense fear of gaining weightdistorted body imageovereating binge eatingintentionally throwing upa lack of control over eating or restricting eatingWhat time does your child typically get into bed? _______ What time does your child typically try to fall asleep?____________What time does your child actually typically fall asleep?___________How many times does your child wake up through the night?__________How long is your child awake each time?__________ What time does your child wake up for the day?__________ What time does your child get out of bed?__________How many hours of sleep does your child need to be rested? ___________ Concerns you have:more than 30 minutes to fall asleep (note how many times per week)waking up in the night and being awake for more than 30 minutes (note how many times per week)waking up more than 30 minutes earlier than desired (note how many times per week)requires excessive reassurance or an extended routine to go to beddemands to sleep with parent(s) or sibling(s)placing your child in bed or adhering to a bedtime is very difficult fear of abandonment in relationshipsunstable relationshipsunstable sense of selferratic behaviorfeeling empty insidereactive mooddifficult to control anger and/or often loses temperdisruptive behavioreasily annoyedoften angry and resentfuloften argues with adultsoften actively defies or refuses to comply with requests or rulesoften deliberately annoys othersoften blames others for his or her mistakes or misbehaviorsverbal aggression physical aggressionoften bullies, threatens, intimidates othersoften initiates physical fightshas used a weapon that can cause serious physical harm to others has been physically cruel to animalshas been physically cruel to peoplestealshas forced someone into sexual activityhas deliberately set fires or destroyed propertyfrequently liesfrequently breaks rulesrepeated urinates or defecates in clothes or bedding or inappropriate places, involuntarily or intentionally, at 5 years old or olderunable to understand social communication and typical interactiondoes not reciprocate / reflect emotions present in otherspoor at understanding and giving nonverbal communicationdifficulty with developing, maintaining and understanding relationshipsrestrictive repetitive patterns of behavior, interests, or activitiesrepetitive motor movementshighly restricted, fixated interests that are abnormal in intensity or focusinsistence of sameness, inflexible adherence to routinesover or under reactive to sensory input from the environment Please list any other things you experience currently and cause you difficulty or concern.Past Psychiatric History:Has your child ever had an appointment with a psychiatrist in the past?__________At what age did your child first see a psychiatrist?______________Has your child been in counseling in the past?________________Please list past psychiatrists and therapists your child has worked with: ________________________________________________________________________________________________________________________________________________________________________Has your child ever been hospitalized for a mental health reason? Yes / NoIf so please provide the year, reason and length of stay: ________________________________________________________________________________________________________________________________________________________________________Please provide any additional information about your child’s past mental health that would be important to know. ________________________________________________________________________________________________________________________________________________________________________Family Mental Health History: Do you know your child’s biological family mental health history? Yes / No Please note what mental health conditions exist in your child’s biological family including any substance use, mental health conditions and/or suicide.________________________________________________________________________________________________________________________________________________________________________Social History:Does your child believe in God? Yes / NoWhat is your child’s religion/church?_____________Who lives with your child? __________ What are the names and ages of your child’s siblings?_________ Year in school:_______Special services/AEA/IEP:_____________Was your child ever held back in school?_______________Name of school:_______________Pets:___________________________________________Any history of abuse against your child? Yes / No If yes, please explain:________________________Is there a gun where your child lives or any other place your child has access to? Yes / No Are there current second hand substance exposures? (like tobacco or drugs) Yes / NoChild using substances him/herself: Yes / NoMedical History: Please list current and past medical conditions. Condition/SurgeryWhen did occur?TreatmentHistory of traumatic brain injury: Yes / NoLoss of consciousness: Yes / NoSeizures: Yes / NoGestation/Birth Drug, Medication or Other Exposures or Trauma: Yes / No Developmental Milestones: Yes / NoBladder/Bowel Milestones/Difficulty: Yes / No ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download