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A Life’s Journey, Inc. Julie Shortridge, MA, LSW, LPC, NCC Patient Self Report: Child and Adolescent (18 and under only) Patient Name: ________________________________________________________ Age: ____ Date: ___________ Name of person completing this form (if not the patient): _______________________________________________ A. Briefly describe the problem which brought you here today. B. What do you want to see changed? C. Why did you decide to seek treatment now? D. Circle below if any behaviors/symptoms/issues that the patient has difficulty with. Risky Signs: Sleep problems Appetite problems Suicidal thoughts/plans Self-injurious/cutting Violent fantasies/urges Runaway risk Hallucinations Inattentive: Fidgety/hyperactive Underachievement Distractibility Disorganized Procrastination Fails to finish things Sad: Sad or blue Negative thinking Guilt/discouraged Hopeless/worthless Crying spells Guilt/low self-esteem Mood swings Relationship: Parenting difficulties Social isolation Difficulty with friends Difficulty with teachers Trauma: Physical Sexual Emotional Rape or assault Addictions/Abuse: Alcohol Drugs Eating disorder Internet 1. Patient’s Current Treatment: Is the patient currently under the care of a therapist and/or psychiatrist? Anger: Short-fused Temper Tantrums Oppositional Fighting Violent/assaultive Bullies/teases Conflictual Other: Tics/Tourettes Lies/steals School problems Failing grades Yes No Yes No Yes No Yes No Provider Names/s: _________________________________________ Counselor Psychiatrist Psychologist Substance Abuse Counselor Psychiatric medications currently taking and effectiveness: ___________________________________________________________ ___________________________________________________________ 2. Patient’s Past Treatment: Has the patient ever been treated in the past For Psychiatric, substance abuse, emotional or behavioral problems: Provider(s) names: ___________________________________________ Counselor Psychiatrist Psychologist Substance Abuse Counselor Psychiatric medications given in the past and results: ___________________________________________________________ ___________________________________________________________ Did you find treatment helpful in the past? Explain: ____________________________________________________ 3. Family’s treatment: Have the patient’s family members currently or In the past been under the care of a therapist and/or a psychiatrist? Provider names/s: ___________________________________________ Counselor Psychiatrist Psychologist Substance Abuse Counselor Psychiatric medications given in past and effectiveness: Cont. Child & Adolescent Intake Form Medical Issues 4. Does the patient have any current medical problems or health issues? If yes, please list: ____________________________________________ Yes No 5. When was the last time the patient was seen by a doctor? ___________________________________________________________ 6. Are immunizations up to date? Yes No 7. Is the patient currently taking medications for medical problems? If yes, please list medications, dosage/frequency and purpose: ___________________________________________________________ ___________________________________________________________ Yes No 8. Are there any allergies and/or medication allergies? Is yes, please list: ____________________________________________ Yes No 9. Is there any history of a head injury, seizures, loss of consciousness, or Extended high fever? If yes, please explain: _________________________________________ Yes No Yes No 11. Were there problems with pregnancy or delivery? If yes, please describe: ________________________________________ Yes No 12. Was there any exposure to alcohol, tobacco, or other drugs during pregnancy? If yes, please describe: _________________________________________ Yes No Yes No Yes No Yes No 10. Would you like information from today’s visit communicated with your Medical doctor? If yes, list MD’s name, phone #, location, address: ___________________________________________________________ Developmental Factors 13. Were there any developmental problems (i.e. did patient walk/talk at appropriate ages)? Describe: ___________________________________ Substance Abuse (SA) 14. Does the patient have/had problems with or treatment for drugs, alcohol or other addiction? If yes, please list: ____________________________________________ SA 1: first use ___ last use _____ pattern of use _________________ Age lost control of use ____ route of use _________________________ Longest period of sobriety ________ history of withdrawal ___________ SA 2: first use ___ last use _____ pattern of use _________________ Age lost control of use ____ route of use _________________________ Longest period of sobriety ________ history of withdrawal ___________ 15. Does the patient currently attend support groups? If so, where: ________________________________________________ 16. Does anyone in the patient’s immediate or extended family has/had problems with drugs, alcohol or other addictions? If so, relationship: ____________________________________________ 17. Does anyone in the patient’s household have problems with drugs, alcohol Or other addictions? If so, whom: _______________________________ 18. Has the patient used any of the following in the last 30 days: Tobacco alcohol marijuana tranquilizers sleeping pills Pain killers’ heroin cocaine/crack amphetamine/speed Methadone LSD PCP ecstasy inhalants crystal meth. Yes No Yes No Yes No Cont. Child & Adolescent Form 19. Have there or are there any problems/trouble related to substance abuse (school, work, legal, DUI)? If yes, please explain: __________________________________________ Yes No Yes Yes Yes Yes No No No No Yes Yes No No 20. Have you ever been a victim of physical, sexual, rape or domestic violence/abuse? If yes, please describe: ___________________________________________ If yes, is it current? Describe: _____________________________________ If yes, do you feel safe? Describe: _________________________________ _ If yes, was it ever reported? Describe: _______________________________ Yes No Yes Yes Yes No No No 21. Have you ever attempted or thought of killing yourself? If yes, please describe: ____________________________________________ If yes, did you obtain treatment? ____________________________________ Yes No 22. Are you currently having thoughts of wanting to kill yourself or someone else? If yes, please describe: ____________________________________________ Yes No 23. Have you ever had a friend or family member commit suicide? If yes, please describe: ____________________________________________ Yes No 24. Does the patient have or had legal issues? If yes, please describe: ____________________________________________ Yes No 25. Is the patient currently on probation or parole? If yes, what for, how long, what for: _________________________________ Yes No 26. Are there currently any legal issues such as: Divorce of parents in progress custody battle going to court Other (please describe): _________________________________________ Yes No 27. Do both parents have legal custody? If not, who has legal custody of the patient? Please describe: _________________________________________________ * Please bring a copy of custody decree on first session Does Father have Joint physical legal custody of patient? Does Mother have Joint physical legal custody of patient? Does someone else have Joint physical legal custody of patient? If yes, please describe: ____________________________________________ Yes No Yes Yes Yes No No No Yes No NA Yes No NA Yes No For ages 10 and up only – please have patient complete the following: - Have you ever ridden in a car driven by you or someone else that was Using alcohol or other drugs? - Do you ever use alcohol or drugs to relax, feel better or to fit in? - Do you ever use alcohol or drugs while you are alone? - Do you ever forget things you did while using drugs or alcohol? - Do your family or friends ever advise you to cut down on your drug or Alcohol use? - Have you gotten into trouble while you were using alcohol or drugs? Risk Factors Legal Issues If there is joint custody, is the other parent aware that the patient Is in counseling? *Per state law, they are required to be notified prior To obtaining treatment. Have they been notified? If yes, their name and phone #: _____________________________ If not, the patient cannot be seen until notified. 28. Is DFACS involved? If yes, please describe: ___________________________ What is the workers name and #: ___________________________________ NA NA NA Cont. Child & Adolescent Intake Form Educational/Work Concerns 29. Are the patients’ grades: above average average below average? If yes, please describe: ____________________________________________ Yes No 30. Has there been a significant decline/drop in the patients’ grades recently? If yes, please describe: ____________________________________________ Yes No Yes No Yes No 35. Does the patient have an SST/IEP/504 qualified? If yes, please describe: ______________________________________________ Yes No 36. Are there any problems related to language/speech/hearing/vision? If yes, please describe: ______________________________________________ Yes No 37. Has your child had a psycho-educational evaluation? If so, when and the results: ___________________________________________ Yes No 38. Are there any special limitations/restrictions/disabilities that impact education? If yes, please describe: _______________________________________________ Yes No 39. Does the patient currently work? If so, please describe: ________________________________________________ Any problems on the job? Please describe: _______________________________ Yes No Yes No Yes No Yes No Yes No 31. Check if any apply: learning disabilities developmental disabilities special education alternative school home schooled If any checked, please describe: _____________________________________ 32. List the patients’ current grade and name of school: ______________________ 33. Is the patient experiencing any problems in school currently? If yes, please describe: _____________________________________________ 34. Does the patient have any history of ISS OSS expulsion suspension Teacher referrals detention Saturday school? If yes, please describe what for/when/how long: _________________________ _________________________________________________________________ NA Family/Relationships 40. Please list anyone who lives in the home with the patient, their age & relationship. Name Relationship Age ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ 41. Please list other extended family or supports involved with patient: ____________________________________________________________________ ____________________________________________________________________ 42. Are both biological parents in the home? If not, please explain: __________________________________________________ divorced separated single parent family step family military Other: ____________________________________________________________ 43. Does the patient have contact with a non-custodial parent? If yes, please describe: _________________________________________________ 44. Does anyone in the immediate family have or had psychiatric, emotional, substance Abuse, trauma or behavioral problems? If yes, whom and please describe: ________________________________________ NA Cont. Child & Adolescent Intake Form 45. Does anyone in your extended family have psychiatric, emotional, substance abuse Or behavioral problems? If yes, whom and describe: ____________________________________________ Yes No Yes Yes No No 47. Has anyone in the immediate or extended family ever attempt/complete suicide? Is yes, please explain: ________________________________________________ Yes No 48. Is anyone in the family not supportive of treatment for the patient? If yes, please describe: _______________________________________________ Yes No 49. Is there a history or current exposure of domestic violence to the patient? If so, please describe: ________________________________________________ Yes No 53. Are there difficulties or concerns about how the patient gets along with others? If yes, please describe: ________________________________________________ Yes No 54. Does the patient have any sexual orientation/gender issues or concerns? If yes, please describe: ________________________________________________ Yes No 55. Are there any financial concerns that would affect the patients’ ability to access tx.? Yes No 56. Do you have access to transportation? Yes No 57. Do you have any disabilities, special needs, or other restrictions that may impact your treatment or access to treatment? If yes, please describe: ______________________________________________ Yes No 46. Has anyone in immediate or extended family been diagnosed with bipolar or Schizophrenia? If yes, please describe: _______________________________ Is yes, have they ever been hospitalized? 50. Please rate the support network of the patients (i.e. church, friends, family, etc.) Excellent very good good fair poor very poor Please describe: ____________________________________________________ 51. List any spiritual/cultural/ethnic considerations that could impact therapy: Please describe: _____________________________________________________ 52. List the patients strengths/resources and hobbies/interests. Please list: __________________________________________________________ Treatment Access/Mobility 58. In your opinion, what would prevent the patients’ ability to change? __________________________________________________________________ __________________________________________________________________ _________________________________________________________________________________ Patient (or person completing this form) signature Date I have reviewed and discussed this information with the patient. _________________________________________________________________________________ Clinician Signature/Credentials Date A Life’s Journey, Inc. August 2011
