Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Male

Female

Mother's Contact Information *

First Name

Last Name

Marital Status

Single

Married

Widowed

Separated

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Father's Contact Information

First Name

Last Name

Marital Status

Single

Married

Widowed

Separated

Date of Birth

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Caregiver's Name (if not parent)

First Name

Last Name

Date of Birth

MM

DD

YYYY

Relationship to Patient

Adoptive

Guardian

Foster

Kinship/Relative

Group Home

Other

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Psychiatric Hospitalization(s): *

Yes

No

Unable to Assess

Outpatient Treatment *

Yes

No

Unable to Assess

Prior Mental Health Records Requested *

Yes

No

Date of Last Physical Exam *

MM

DD

YYYY

Pediatrician's Phone *

(###)

###

####

Please select all that apply: *

Glasses

Seizure/Neuro Disorder

Accidents

Dental

Sexually Transmitted Diseases

Allergies

Braces

Acute Illness

Head Trauma

Vaccinations

Weight or Appetite Change

Pregnant

Sensory/Motor Complaint

Chronic Illness

Hearing Problems

Asthma/Lung Disease

HIV Test

None

Neonatal: Prenatal Care? *

Yes

No

Did Mother use alcohol, cigarettes, drugs? *

Yes

No

Special Education *

Yes

No

Special Classes *

Yes

No

IEP *

Yes

No

DCFS or Police Intervention *

Yes

No

Is there a current visitation/involvement plan? *

Yes

No

Living Situation Type *

Biological

Adoptive

Guardian

Foster

Kinship/Relative

Group Home

Other

Is the patient homeless? *

Yes

No

Unable to Assess

If yes, when did the patient become homeless (estimated date)? *

MM

DD

YYYY

Others diagnosed with mental illness in living situation? *

Yes

No

Significant current drug/alcohol use in living situation? *

Yes

No

Initial Date of Living Situation: *

MM

DD

YYYY

History of mental illness in immediate family *

Yes

No

Unable to Assess

Alcohol/drug use in immediate family *

Yes

No

Unable to Assess

History of incarceration in immediate family *

Yes

No

Unable to Assess

Living Situation Type *

Biological

Adoptive

Guardian

Foster

Kinship/Relative

Group Home

Other

Others diagnosed with mental illness in living situation? *

Yes

No

Significant current drug/alcohol use in living situation? *

Yes

No

History of mental illness in immediate family *

Yes

No

Unable to Assess

Alcohol/drug use in immediate family *

Yes

No

Unable to Assess