New Child and Adolescent Questionnaire - Concord Behavioral Health

First Name

Last Name

Date of Birth

Street Address

City

State

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.

New Child & Adolescent Patient Questionnaire