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11955 DALLAS PKWY, FRISCO | M-F 8-6 SAT 9-12 SUN 2-4
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11955 Dallas Parkway, Frisco
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M-F 8-6 | Sat 9-12 | Sun 2-4
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Admin: Mental Health Evaluation
Admin: Mental Health Evaluation
Michael
2021-02-25T08:40:16-06:00
Patient's Name
*
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Patient's Date of Birth
*
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1. Has the patient talked about committing suicide, attempted to commit suicide or displayed self-harming behaviors (e.g. cutting)?
*
No
Yes
Refer patient to a psychiatrist. Use the
referral page
on our website.
2. Has the patient reported hallucinations or has the patient been delusional?
*
No
Yes
Hallucinations:
seeing, hearing or smelling things that are not really there.
Delusions:
untrue beliefs (e.g. receiving secret messages through TV or radio). Usually presents as paranoia ("someone is out to get me")
Refer patient to a psychiatrist. Use the
referral page
on our website.
3. What is the patient's age?
*
3
4
5
6
7
8
9
10
11
12
13
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17
4. Has the patient had any previous evaluations with a speech therapist, physical or occupational therapist, school psychologist, private psychologist and/or psychiatrist?
*
No
Yes
Request evaluations from parent. Provider must have a copy of ALL prior evaluations BEFORE scheduling an appointment.
5. Does the patient currently have a 504 or IEP in place at school? (Your child has an IEP or 504 Plan if they receive special education services, such as participating in the Dyslexia program, receiving resource instruction, receiving speech, physical or occupational therapy services at school, and/or accommodations for any mental health or medical diagnoses.)
*
No
Yes
Request copies of 504 or IEP from parent. Provider must have a copy of ALL 504 or IEP documents BEFORE scheduling an appointment.
6. Has the patient been seen by a neurologist and/or had genetic testing?
*
No
Yes
Request neurologist and/or genetic testing medical records. Provider must have a copy of ALL medical records BEFORE scheduling an appointment.
Please list the names of ALL teachers that will receive the Vanderbilt Questionnaire from the parent.
Verify Required Questionnaires
Based on the patient's answers, the following questionnaires are required to complete the Mental Health Intake. Check all questionnaires to be completed.
Vanderbilt ADHD Diagnostic Rating Scale – Parent (5 to 17 years of age)
- Vanderbilt ADHD Diagnostic Rating Scale – Parent (5 to 17 years of age)
Vanderbilt ADHD Diagnostic Rating Scale – Teacher (5 to 17 years of age)
- Vanderbilt ADHD Diagnostic Rating Scale – Teacher (5 to 17 years of age)
ASAS (8 o 17 years of age)
- ASAS (8 o 17 years of age)
SCAS (age 7)
- SCAS (age 7)
PAS (3 to 6 years of age)
- PAS (3 to 6 years of age)
Mood and Feelings (6 to 17 years of age)
- Mood and Feelings (6 to 17 years of age)
AQ-10 Questionnaire (4 to 11 years of age)
- AQ-10 Questionnaire (4 to 11 years of age)
RCADS Questionnaire (8 -17 years of age)
- RCADS Questionnaire (8 -17 years of age)
SCARED Questionnaire (8 -17 years of age)
- SCARED Questionnaire (8 -17 years of age)
AQ-10 Adolescent Questionnaire (12-15 years of age)
- AQ-10 Adolescent Questionnaire (12-15 years of age)
Intake Questionnaire (3 to 17 years of age)
- Intake Questionnaire (3 to 17 years of age)
Verify Required Documents
Based on the patient's answers, the following documents are required to complete the Mental Health Intake. Check all documents to be requested.
Documents to request
- None
Previous mental health evaluations with a school psychologist, private psychologist and/or psychiatrist
- Previous mental health evaluations with a school psychologist, private psychologist and/or psychiatrist
504 or IEP documents
- 504 or IEP documents
Records from neurologist and/or genetic testing
- Records from neurologist and/or genetic testing
Patient Email
*
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