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 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:
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:*
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? YesNo
If so, what kind? PhysicalSexualNeglect
If so, was the abuse ever reported to authorities? YesNo
Has the patient ever witnessed domestic violence in the home? YesNo
Is domestic violence currently occurring in the child’s home? YesNo
Current or previous DCF involvement? YesNo
If yes, please explain:
What extracurricular activities does the patient engage in at this time?
Has he or she ever been employed? YesNo
School name and grade:
List any grades repeated by the patient:
Behavioral difficulties? YesNo
If yes, please describe:
Difficulties with academics? YesNo
Does the patient have an Individualized Education Plan (IEP)? YesNo
If yes, do you know the reason for the IEP (i.e. learning disability):
Patient’s birth weight and height:
Was the patient adopted? YesNo
Method of delivery? VaginalCesarean
Complications at birth? YesNo
Did the patient meet developmental milestones on time: YesNo
If no, describe below
Current medical concerns:
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? YesNo
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? YesNo
Is the patient currently experiencing suicidal thoughts? YesNo
Current Symptoms (check all occurring in the last two weeks): Sleep disturbanceAnxiety/WorrySadnessProblems with friendsAppetite changesCrying more than normalSocial isolationHopelessnessPoor concentrationApathyTrouble making decisionsAnger/hostilityFatigue/Lack of energyUnable to sit stillHearing voicesPoor self esteem
Please describe symptoms not listed in the table above:
Has the patient ever been arrested of involved in any type of legal proceeding? YesNo
Does the patient have a history of any substance abuse? YesNo
If so, please list the substances and the patient’s treatment history:
By checking the box, I agree that the above information is accurate and true.
