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New Child and Adolescent Questionnaire
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2016-08-04T01:13:17-05:00
New Child & Adolescent Patient Questionnaire
If you are a human and are seeing this field, please leave it blank.
First Name
Last Name
Date of Birth
Street Address
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip / Post Code
Billing address (if different)
Preferred Daytime Phone
Is this a cell phone?
Yes
No
Phone (Other)
Email
Preferred method of automated appointment reminder
Text
Email
Phone
Name of Parents/Guardians
Who does patient live with?
School
Grade
IEP
How would you prefer that we communicate with you?
Phone
Voice Mail
Text
Email
If applicable, who is your current therapist?
Who is your PCP, if different than referring provider?
Is it okay for us to leave a voice mail at the phone numbers you listed above?
Please indicate below the general nature of the service you are seeking:
Psychiatric evaluation/consultation
Medication management
Other
If applicable, who referred you to Concord Behavioral Health
Please briefly outline below your reason for requesting a visit to CBH.
If you are presently taking any medications for psychiatric purposes, please list them below, and indicate who is prescribing them (PCP, family doctor, APRN, psychiatrist, etc.)
Please briefly outline any past outpatient psychiatric treatment that you have received.
Past provider(s) and how long with each provider?
Have you been on other medications in the past for mental health reasons? If so, please list as many as you recall, and any reason why these medications were discontinued.
Do you presently struggle with thoughts of suicide?
Have you ever had thoughts of suicide?
Have you ever acted on thoughts of suicide?
Has anyone in your family committed suicide?
Have you been to the emergency room for mental health reasons?
Have you ever been hospitalized for mental health reasons? (Please list hospitalizations, and dates.)
Do you drink alcohol?
If so, how much alcohol do you drink in an average week?
Do you use any substances or medications, prescription or otherwise, for non-medical (recreational) purposes? (If so, please describe use.)
Have you ever been hospitalized for substance abuse or detox?
Please list any chronic medical issues.
Please list medications you are prescribed for these issues.
Describe milestones for walking, talking, social development. On time? Concerns?
Insurance/Managed Care Company
Insurance phone number for providers found on back of card
Name of primary insurance subscriber
Birthdate of primary insurance subscriber
ID number of primary insurance subscriber
Insurance group name or number
Insurance Company address on back of card
If known, what is your copay/co-insurance for primary care, and do you have a deductible?
Please indicate if you use a mail order pharmacy or a local pharmacy, and the relevant phone number.