Medication Appointment - Child

Patient First Name *

Middle Initial

Patient Last Name *

Suffix

Date of birth * +

Age *

Gender *

Male

Female

Parent / Guardian First Name *

Parent / Guardian Last Name *

Parent / Guardian's marital status: *

Single

Married

Separated

Divorced

Married to child's bio mom / dad *

Yes

No

Are you the custodial / decision making parent meaning you have legal documentation stating the other parent does not have this right. OR do you have joint custodial rights and / or decision making authority?

Yes

No

Joint

Please attach supporting documentation. This could include court documents, divorce decree, adoption papers, birth certificate, etc. If you have any questions, please contact our office at 719-540-2146 or 719-540-2177 before continuing.

Verification of decision making paperwork.

Parent / Guardian Mailing Address *

Address Line 2

City *

State *

Zip Code *

What is the preferred number to reach you at? *

Phone Number *

Would you like to add another contact number? *

Yes

No

Phone Number

Best time to call *

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

We provide courtesy appointment reminders. If you would like to receive a reminder, please let us know which method you prefer or you may opt out. Standard messaging rates may apply for texts. Confirmation reminders are a courtesy only. It is still your responsibility to make all your appointment. *

Text

Call

I opt out

Cell Carrier? *

Best time to call

7:30 - 9:00

9:00 - 12:00

12:00 - 3:00

3:00 - 5:00

Email Address *

In cases of divorce, separation, or when legal custody is not previously established above, we are required to let both custodial parents / guardians know that the child is in treatment. By selecting this box you are affirming that you are not aware of the whereabouts of the your child's other parent and you've exhausted all attempts to let them know their child is in treatment. *

Agree

Other Parent / Guardian First Name *

Other Parent / Guardian Last Name *

Mailing Address *

Address Line 2

City *

State *

Zip Code *

Other Parent / Guardian Phone Number

Email Address *

Emergency contact information

	Name	Phone number	Relationship
1	Name	Phone number	Relationship
2	Name	Phone number	Relationship

Responsible Financial Party

We require a credit card to be placed on file. Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees. Credit card information must be entered even if you are not the responsible party.

TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees.

No Show / Late Cancellation Policy

By checking this box, you acknowledge that you have read the no show / late cancellation policy. *

Agree

Is financial responsibility someone other than the patient? *

Yes

No

Name on Card *

Credit Card Type *

Credit Card Number *

Expiration Date (mm/yy) *

Security code. *

By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

I agree

First Name *

Last Name *

SSN *

Street Address

Address Line 2

City

State

Zip Code

Home Phone Number

Work Phone Number

Cell Phone Number *

Email address *

Referral Information

Who referred you to Family Care Center? *

Name and number of your primary care physician / pediatrician if know?

Name and number of therapist if know?

Presenting Problem

What are the problems or concerns you are having? *

When did the problem begin and for how long has it gone on? *

How often does the problem occur? *

What triggers the problem? *

Identify times and places when the problem is NOT present? *

Have you tried to solve this problem? *

What does your child say about the problem? *

How do you see yourself participating in solving the problem? *

Current Symptom Checklist

Please mark each item even if you are not absolutly certain. Give answers on the child's behavior over the last six months.

*

	Not True	Somewhat True	Certainly True
Considerate of other people's feelings	Not True	Somewhat True	Certainly True
Restless, overactive, cannot stay still for long	Not True	Somewhat True	Certainly True
Often complains of headaches, stomach-aches or sickness	Not True	Somewhat True	Certainly True
Shares readily with other children, i.e. toys, treats, pencils	Not True	Somewhat True	Certainly True
Often loses temper	Not True	Somewhat True	Certainly True
Rather solitary, prefers to play alone	Not True	Somewhat True	Certainly True
Generally well behaved, usually does what adults request	Not True	Somewhat True	Certainly True
Many worries or often seems worried	Not True	Somewhat True	Certainly True
Helpful if someone is hurt, upset, or feeling ill	Not True	Somewhat True	Certainly True
Constantly fidgeting or squirming	Not True	Somewhat True	Certainly True
Has at least one good friend	Not True	Somewhat True	Certainly True
Often fights with other children or bullies them	Not True	Somewhat True	Certainly True
Often unhappy, depressed, or tearful	Not True	Somewhat True	Certainly True
Generally liked by other children	Not True	Somewhat True	Certainly True
Easily distracted, concentration wanders	Not True	Somewhat True	Certainly True
Nervous or clingy in new situations, easily loses confidence	Not True	Somewhat True	Certainly True
Kind to younger children	Not True	Somewhat True	Certainly True
Often lies or cheats	Not True	Somewhat True	Certainly True
Picked on or bullied by other children	Not True	Somewhat True	Certainly True
Often offers to help others	Not True	Somewhat True	Certainly True
Thinks things out before acting	Not True	Somewhat True	Certainly True
Steals from home, school, or elsewhere	Not True	Somewhat True	Certainly True
Gets along better with adults than with other children	Not True	Somewhat True	Certainly True
Many fears, easily scared	Not True	Somewhat True	Certainly True
Good attention span, sees work through to the end	Not True	Somewhat True	Certainly True

Treatment History

Prior OUTPATIENT psychotherapy? *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Therapist information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Treatment Modality (check all that apply)

Which, if any, were beneficial?

Has any family member had either inpatient or outpatient mental health treatment? *

Yes

No

Who and for what reason or diagnosis and where they given any medications? (list all here)

Prior INPATIENT treatment for psychiatric, emotional, or substance use disorder? *

Yes

No

How many times?

Dates if known.

+-

Diagnosis *

Inpatient facility information

	Name	City, State	Phone number
1	Name	City, State	Phone number
2	Name	City, State	Phone number
3	Name	City, State	Phone number
4	Name	City, State	Phone number
5	Name	City, State	Phone number

Treatment Modality (check all that apply)

Which, if any, were beneficial?

Prior or current psychotropic medication use? *

Yes

No

List all psychotropic medications below.

	Medications	Dosage	Side Effects	Beneificial
Medication #1	Medications	Dosage	Side Effects	Beneificial
Medication #2	Medications	Dosage	Side Effects	Beneificial
Medication #3	Medications	Dosage	Side Effects	Beneificial
Medication #4	Medications	Dosage	Side Effects	Beneificial
Medication #5	Medications	Dosage	Side Effects	Beneificial
Medication #6	Medications	Dosage	Side Effects	Beneificial

Family History

Parents current marital status: *

Married to child's bio mom / dad

Divorced

Separated

Deceased

Separated for how long?

Divorced for how long?

Which parent and for how long?

What was the age of the parent when they passed away?

Mother remarried?

Yes

No

How many times?

Father remarried?

Yes

No

How many times?

Mother involved with someone?

Yes

No

Father involved with someone?

Yes

No

Present during your childhood:

	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Mother	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Father	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Stepmother	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Stepfather	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Brother(s)	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A
Sister(s)	Present Entire Childhood	Present Part of Childhood	Not Present at All	N/A

Anybody else not listed above?

List all persons currently living in your household.

	Name	Age	M / F	Relationship to patient
1	Name	Age	M / F	Relationship to patient
2	Name	Age	M / F	Relationship to patient
3	Name	Age	M / F	Relationship to patient
4	Name	Age	M / F	Relationship to patient
5	Name	Age	M / F	Relationship to patient

Any other family supports we should know about?

Medical History (check all that apply)

Describe your current health. *

Good

Fair

Poor

List any known allergies or put NKA. *

Birth: *

Normal delivery	Difficult delivery
Cesarean delivery	Complications Complications

Birth weight?

Problems during mother's pregnancy? *

Infancy: *

Feeding problems	Sleep problems
Toilet training problems

Delayed developmental milestones? (Only select those milestones that did not occur at expected age.) *

Please select all that apply below pertaining to childhood health:

Chickenpox? *

Yes

No

Age?

German measles? *

Yes

No

Age?

Red measles? *

Yes

No

Age?

Rheumatic fever? *

Yes

No

Age?

Whooping cough? *

Yes

No

Age?

Scarlet fever? *

Yes

No

Age?

Lead poisoning? *

Yes

No

Age?

Mumps? *

Yes

No

Age?

Poliomyelitis? *

Yes

No

Age?

Diphtheria? *

Yes

No

Age?

Pneumonia? *

Yes

No

Age?

Tuberculosis? *

Yes

No

Age?

Ear infections? *

Yes

No

Asthma? *

Yes

No

Other chronic, serious health problem? *

Yes

No

Describe.

Any other medications being taken not previously mentioned? *

Yes

No

List any medications currently being taken.

	Medication	Dosage	Reason
1	Medication	Dosage	Reason
2	Medication	Dosage	Reason
3	Medication	Dosage	Reason
4	Medication	Dosage	Reason
5	Medication	Dosage	Reason

Any serious hospitalizations or accidents? *

Yes

No

Describe.

	Date	Age	Reason
1	Date	Age	Reason
2	Date	Age	Reason
3	Date	Age	Reason
4	Date	Age	Reason

Any abnormal labs? *

Yes

No

Describe.

	Date	Result
1	Date	Result
2	Date	Result
3	Date	Result
4	Date	Result

Name and phone number of psychiatrist if known.

Substance Use History

Substances Used:

Alcohol *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Amphetamines/speed *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Barbiturates *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Cocaine *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Crack cocaine *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Hallucinogens (e.g., LSD) *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Inhalants (e.g., glue, gas) *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Marijuana or hashish *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Nicotine/cigarettes *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

PCP *

Yes

No

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Prescription drugs *

Yes

No

Which drug if yes? Which drug if yes?

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Others not listed *

Yes

No

Which drug if yes? Which drug if yes?

	First use age	Last use age	Current use Y or N	Frequency	Amount
1	First use age	Last use age	Current use Y or N	Frequency	Amount

Consequences of substance use

Have you ever had treatment for substance abuse *

Yes

No

Substance use treatment history

	Age	Successful
Outpatient	Age	Successful
Inpatient	Age	Successful
12-step program	Age	Successful
Stopped on own	Age	Successful
Other	Age	Successful

Family substance abuse history *

	Check all that apply
	yes	no	N/A
Father	yes	no	N/A
Mother	yes	no	N/A
Grandparents(s)	yes	no	N/A
Sibling(s)	yes	no	N/A
Step-parent / live-in	yes	no	N/A
Uncle(s) / Aunt(s)	yes	no	N/A
Spouse / significant other	yes	no	N/A
Children	yes	no	N/A
Other	yes	no	N/A

Socio-Economic History (check all that apply)

Housing situation: *

Mom's employment. *

Dad's employment. *

Financial situation: *

Social support system: *

Parents military history: *

Which parent deployed?

Number of deployments.

Deployment dates and location.

+-

Observed effect on child?

+-

Current legal issues? *

Yes

No

Describe last legal difficulty.

Activities

	Yes	No
Currently active in community / recreational activities	Yes	No
Formerly active in community / recreational activities	Yes	No
Currently engage in hobbies	Yes	No
Currently engage in spiritual activities	Yes	No

Sexual Orientation Child Identifies with?

If other, describe.

Is child currently sexual active?

Yes

No

Age of child's first sexual experience

If applicable, age of child's first pregnancy / fatherhood

Ethnicity

Religion

Describe any cultural issues that contribute to current problem:

Notices

Patient Grievances

Patient Rights

Non-discrimination Notice

Notice of Privacy Practices

By checking this box, you acknowledge that you have read the notices above. *

Agree

Acknowledgement and Signature

By signing this form, you agree that your child will be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Parents / guardians are responsible for all payments at time of service. Clients who do not show up for this initial appointment or any subsequent follow-up appointments are subject to a $50 no-show fee which must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in child not being accepted as a client. *

clear

Cognitive Behavioral Therapy	EMDR
Dialectical Behavioral Therapy	Play Therapy
TheraPlay	Not Known
Other Other

Cognitive Behavioral Therapy	EMDR
Dialectical Behavioral Therapy	Play Therapy
TheraPlay	Not Known
Other Other

None	High blood pressure	Kidney infection
German measles	Emotional stress	Bleeding
Alcohol use	Drug use	Cigarette use
Other Other

Sitting	Rolling over	Walking
Feeding self	Riding tricycle	Controlling bowels
Standing	Engaging peers	Tolerating separation
speaking sentences	Controlling bladder	Sleeping alone
Speaking words	Riding bicycle	Dressing self
Playing Cooperatively	Other Other

Hangovers	Blackouts	Tolerance changes	Suicidal ideations
Withdrawal symptoms	Sleep disturbance	Binges	Seizures
Medical conditions	Assaults	Job loss	Arrests
Overdose	Loss of control	Relationship conflicts	Other Other