Adolescents and Teens Assessment Form

    Demographic Information

    Date:*

    Patient Name*

    Name of person completing form:

    Relationship to patient if other than patient*

    Patient DOB:*

    Home Address:*

    Phone Number:*

    Your email*:

    Referred by:


    Insurance/Billing Information

    Insurance Company Name:*

    Policy or ID number:

    Group or Account number:

    Name of Policy Holder:

    Address and Phone Number of Policy Holder (if different from above):

    Policy Holder DOB:


    Parent Consent

    We MUST have at least one parent signature, EXCEPT in cases where parents of a patient are divorced; both parents must consent at the start of treatment (additional form required to sign can be sent to parent via email). Sessions will not be held unless both parents consent to the patient receiving treatment at Hope Restored Services, in accordance with Florida law.

    Parents signature:*


    Patient History

    Please state the presenting problem*:

    How long has this problem existed*?

    Please name the people who reside in your home (Include relationship and age):

    Has the patient ever suffered abuse?

    If so, what kind?

    If so, was the abuse ever reported to authorities?

    Has the patient ever witnessed domestic violence in the home?

    Is domestic violence currently occurring in the child’s home?

    Current or previous DCF involvement?

    If yes, please explain:

    What extracurricular activities does the patient engage in at this time?

    Has he or she ever been employed?


    Educational History

    School name and grade:

    List any grades repeated by the patient:

    Behavioral difficulties?

    If yes, please describe:

    Difficulties with academics?

    If yes, please describe:

    Does the patient have an Individualized Education Plan (IEP)?

    If yes, do you know the reason for the IEP (i.e. learning disability):


    Medical History

    Patient’s birth weight and height:

    Was the patient adopted?

    Method of delivery?

    Complications at birth?

    If yes, please explain:

    Did the patient meet developmental milestones on time:

    If no, describe below

    Current medical concerns:


    Psychiatric History and Symptom Inventory

    List the patient’s three most stressful issues as reported by the patient:

    Does the patient have a history of receiving mental health counseling, behavioral therapy, inpatient psychiatric care, or outpatient medication management by a psychiatrist or neurologist?

    If so, please list below (name of provider and date of service):

    Family psychiatric history:

    Psychiatric medication history: Please list below the medications that the patient has been prescribed for psychiatric reasons. Place an asterisk (*) next to those that the patient is currently taking.

    Medication, dosage and duration on medicine:

    Has the patient ever attempted to commit suicide?

    If yes, please describe:

    Is the patient currently experiencing suicidal thoughts?

    If yes, please describe:

    Current Symptoms (check all occurring in the last two weeks):

    Please describe symptoms not listed in the table above:


    Legal History

    Has the patient ever been arrested of involved in any type of legal proceeding?

    If yes, please explain:


    Substance Abuse History

    Does the patient have a history of any substance abuse?

    If so, please list the substances and the patient’s treatment history: