New Patient Assessment

Dear Client,

The following information will help the clinic staff obtain an understanding of you and/or your spouse/significant other (SO) as quickly as possible. Please complete it to the best of your ability, and do not worry if you are unable to answer some the questions.

Thank you very much.

Patient's First Name *

Patient's Last Name *

Nickname

Full Address *

Date of Birth *

Age *

Primary Phone Number *

Secondary Phone Number

Email Address *

Person Completing Form
(if different from patient)

Relationship to Client

Client's School

Client's Grade Level

Family members

	In-Home	Name	Age	Relationship	Highest Grade	Remove

Mother's Marital Status:

Father's Marital Status:

If parents are separated/divorced, who has physical custody?

How often does the non-custodial parent see the child(ren)?

Employment

Patient's Job/Profession

Patient Hours Worked Weekly

Spouses's Job/Profession

Spouse Hours Worked Weekly

Approximate gross family annual income from all sources (optional)?

Major Problems/Concerns *

What are the MAJOR problems/concerns for which you are coming to the clinic? *

What kinds of help do you believe you need? Please check all that apply. *

Evaluation/Assessment only

Psycho-education/counseling

Psychotherapy

Not Sure

Please indicate any stressful events that you believe may be related to the problems noted above:
How have the problems changed since you first noticed them?

Problem Checklist

Please review the following list of common behavior/emotional problems. Select the appropriate option to indicate the extent to which each symptom describes you.

Depressed or irritable mood, lack of interest or motivation, boredom or withdrawal from friends *

Sleep or appetite/weight changes *

Multiple apparently unfounded medical complaints *

Self-esteem decreased/excessive self-blame and guilt *

Suicidal behavior or thoughts *

Increased tearfulness or rapid changes of mood *

Has a hard time making/keeping friends *

Overactivity *

Distractibility/inattentiveness/fidgeting *

Impulsivity *

Difficulty following through on instructions *

Loses things easily *

Shifts from one incomplete activity to another *

Argumentative, angry, or vindictive behavior *

Refuse to comply with reasonable rules/laws or regulations *

Annoys other deliberately *

Stealing/forgery/breaking and entering *

Lying *

Fire-setting *

Homicidal/dangerous behavior or plans *

Cruelty to animals or people *

Physical fights *

Arrests

Binge eating *

Use of laxatives/diuretic/diet pills *

Fasting/strict dieting not prescribed by a doctor *

Persistent concern with body shape/weight *

Fearful about being separated from you (at school, at night, being left with a sitter) *

Fear that harm will come to you/them during absences (killed, kidnapped, accident) *

Painfully or excessively shy when around unfamiliar people *

Unpleasant thoughts in head or discusses being afraid that he might do something wrong *

Substance use, abuse, or suspected abuse *

Check all that apply.

Alcohol

Marijuana

Cocaine

Heroin/Opium

Tranquilizers

Hallucinogens/LSD/PCP

Has bizarre ideas/odd behavior *

Sees/hears things that others do not *

Behavior is grossly disorganized *

Speech does not make sense to others (loosely connected, rambling, etc.) *

Withdrawn from others/little social contact *

Functioning below highest level preciously achieved *

Little or inappropriate expression of feelings *

Please explain any other problems not already mentioned:

Past Psychiatric History

Previous history of psychiatric/psychological/drug or alcohol evaluation or treatment. *

If yes, please provide details as to when/when treatment was sought.

Medication for psychiatric/emotional/attentional problems, now or previous. *

Psychiatric Medications

Medication	Dose	Date

Is there a history of suicide attempt(s)? *

Suicide Attempts

Circumstances	When	Remove

Hospitalizations for psychiatric or drug problems? *

Psychiatric Hospitalizations

Circumstances	When	Remove

Involvement with juvenile court/probation officer? *

Any involvement with Child Protective Services? *

Medical History

Name of primary care physician:

Date of Last Visit:

Previous hospitalizations, surgeries, or major illnesses (list below) *

Medical Hospitalizations

Circumstances	Treatment/Outcome	When	Remove

Traumatic head injuries? *

Please describe nature of head injuries(When/Where).

Allergies to medications *

Please list medicine allergies.

Other allergies (e.g., specific food allergies, ragweed, cats, etc.) *

Please list other allergies.

Chronic Earaches? *

Please explain issues related to earaches.

Tube Surgery? *

If yes, what age?

Date of last hearing test?

Date of last vision test?

Developmental and Perinatal History

Full Term? *

If not full term, how many weeks?

Were medications for the mother necessary? *

If yes, please specify.

Drugs or other toxic substances (including smoking) to which mother was exposed? *

Other Illnesses?

Child(ren) Condition at Birth

Overall Health	Pounds	Ounces	Remove

First Year of Life

Feeding Problems? *

Sleeping Problems? *

Bonding Problems? *

Please provide any additional First Year of Live details, if applicable.

Academic History

How would you describe yourself as a student in school?
Primary School Middle School High School College

Leisure Activities

Please tell us some of the hobbies/activities.

Family History

Family Stressors (please check all that apply)

Marital conflicts

Parent/Child conflict

Physical Illness/medical problems

Recent deaths

Sexual/physical abuse

Drug/alcohol abuse by parents

Frequent moves

Financial problems

Other

Please indicate the presence in biological relatives of any psychiatric problem, such as depression, suicide, alcoholism, drug abuse, anxiety panic attacks, manic-depressive (bipolar) illness, schizophrenia, mental retardation, autism, learning disability, hyperactivity, attention deficit disorder, childhood behavior problems, school or academic problems, narcolepsy, legal problems, brain trauma.

Your Father *

Father's parents, brothers, or sisters *

Your mother *

Mother's parents, brothers, or sisters *

Your brothers and sisters *

Other biological relatives *

Family Circumstances

Please provide any information about the family that you think would be important in our understanding of the current problem:

Current Functioning

Please select from the following scale to indicate how well you are coping currently. 100% means you are coping the highest reasonably expected. *

THANK YOU FOR YOUR TIME AND EFFORT!