Admin: Mental Health Intake | Pediatric People

Patient Information

Name*

First Last

Nickname

Age*

Please enter a number from 1 to 100.

Date of Birth*

Grade*

Home Phone*

Cell Phone

Email

Address*

Street Address Address Line 2 City State ZIP Code

Alternate Address (if living with parents & step-parents)

Street Address Address Line 2 City State ZIP Code

School Information

School*

Address

Street Address Address Line 2 City State ZIP Code

Phone

Guidance Counselor

Phone

Case Manager

Phone

Primary Health Care Provider

Name

Address

Street Address Address Line 2 City State ZIP Code

Phone

Parent/Step-Parents/Guardian Contact Information

Mother's Name

Mother's Occupation/Employer

Mother's Work Phone

Mother's Home Phone

Mother's Cell Phone

Mother's Email

Father's Name

Father's Occupation/Employer

Father's Work Phone

Father's Home Phone

Father's Cell Phone

Father's Email

Step-Parent/Guardian's Name

Step-Parent/Guardian's Occupation/Employer

Step-Parent/Guardian's Work Phone

Step-Parent/Guardian's Home Phone

Step-Parent/Guardian's Cell Phone

Step-Parent/Guardian's Email

Siblings

List names and ages of siblings in the home.

Name	Age

ADHD Information

If ADHD, when was the ADHD diagnosed?

Diagnostician

Are there any known disabilities or co-existing conditions (depression, anxiety, OCD, other)?*

Yes
No

If yes, please explain.*

Is your child currently taking medication for ADHD or any other related difficulty, such as depression or anxiety?*

Yes
No

If yes, which medication(s) and how often?*

Medication:	How often:

Are there any other medications taken?*

Yes
No

If yes, name of medication and for the treatment of?*

Medication name:	For the treatment of:

Does your child have special accommodations per an IEP or 504?*

Yes
No

If yes, briefly describe eligibility.*

Has your child ever worked with a coach or organizational consultant to assist with ADHD or learning difficulties?*

Yes
No

If yes, when and what was the focus of the work?*

Has your child worked with a tutor?*

Yes
No

If yes, for which subjects?*

Are there family members with ADHD?*

Yes
No

If yes, who would that be?*

Are you concerned or aware of alcohol, substance abuse or recreational drug use by your child?*

Yes
No

How well do you feel you and your family understand ADHD and/or Executive Functioning Disorder?

Little to no knowledge	Basic knowledge definition & what medication does	Fairly well (read books, talk to doctors)	Very well (experienced daily)

Do you have a family calendar?*

Yes
No

If yes, who usually keeps it current?*

If no, are you willing to start using a family calendar when therapy/coaching begins?*

Yes
No

Do you use a reward system with your child?*

Yes
No

If yes, please describe.*

School/Learning Experiences

Alternate Paths: Has your child been homeschooled, repeated a grade or dropped out of school?*

Yes
No

If yes, please explain.*

Describe your child's strengths and area of passion:*

Describe your child's outdoor activities and/or school/club athletic endeavors:*

Describe your child's strengths:*

How does your child currently feel about school? What are his/her favorite things about school?*

How does your child relate to peers? Does your child like to have many friends or perhaps perfers one or two close friends?*

How does your child deal with transitions to new situations such as starting a new school year, moving (houses or states), trying new activities, new foods, etc?*

Is there a particular subject area that you child enjoys, or shows advances in, or above grade level ability?*

Does your child have difficulty in any of the following?*

Select All
Speech
Reading
Writing
Spelling
Math
Social/Friends

If any of the above were checked, please explain.*

Does your child have any organizational difficulties?*

Yes
No

If yes, please explain.*

Do you have any other concerns about your child’s school life, academic performance, or social interactions that have not been shared so far?*

Yes
No

If yes, please explain.*

To better understand what's going on at school, may I contact your child's teacher(s) for further information about progress and further observations?*

I’d prefer that you go through a parent
Yes

Please speak to:*

Name	Email	Phone Number

(ie, English teacher, Math teacher, Science teacher, Social Studies teacher, Elective teachers/Coaches, Vice Principal, Other)

Parents Portal

I’d like to have access to your child’s grades, assignments and assessments (tests/quizzes), if part of the coaching process includes academic performance and school related activities. Please provide the school's parent portal information and your login as well as your child’s (if you know it).

Web Address

Parent's Login Username

Parent's Password

Child's Login Username

Child's Password

In your observations, which skill(s) need to be worked on, or are lacking? Please check all that apply.*

Additional Information

What concerns you about how your child is acting/doing or not doing at home or school? Specially, why have you thought it best to address these issues at this time?*

Did these issues or your concerns, appear before now? If so, have they come and gone away from time to time? Can you pinpoint what causes them to come to the surface as well as pinpointing when they are not a challenge?*

How have you tried to address these things with your child? Sharing your concerns with your child, utilized ‘teaching moments,' rewards or punishments? What is the typical outcome of discussions?*

In your observation, what has worked best and what has not been effective at all?*

Do any of your concerns seem to affect your child’s self-esteem or social interaction with peers? Is this something your child recognizes in himself or herself?*

If your child had a choice, do you think he or she would like to work on these things? If so, why now? Keep in mind that even though your child may come across as not noticing or refuse to have a discussion with you about it, your child would prefer for things to be in harmony and not at odds with parents, siblings, peers or teachers.*

Specify as clearly as possible your desired outcome goals for your child.*

Dear Parent, My thoughts on how important our job of raising children are and why I truly believe this is one of the hardest things we’ve ever had to do: Here is a quote I like to share: “No one is ever quite ready; everyone is always caught off guard. Parenthood chooses you. And you open your eyes, look at what you’ve got, say “Oh, my gosh,” and recognize that of all the balls there ever were, this is the one you should not drop. It’s not a question of choice.” - Marisa de los Santos, author of Love Walked In On the lighter side: “I wish I was a kid, so I can take a long nap and everyone would just be proud of me." - unknown

Consent & Agreement*

I have received and read the information disclosure statement and agree to the terms.

INFORMATION DISCLOSURE STATEMENT

Therapy/coaching is a relationship that works in part because of clearly defined rights and responsibilities held by each person. This framework helps to create the safety to take risks and the support to become empowered to change. As a client, you and your child have certain rights. There are also certain limitations to those rights that you should be aware of. As a therapist/coach, I have corresponding responsibilities to you.

My Responsibilities to You
CONFIDENTIALITY With the exception of certain specific exceptions described below, you have the absolute right to the confidentiality of your treatment. I cannot and will not tell anyone else what you have told me, or even that you are a client in treatment with me without your prior written permission. Under the provisions of the Health Care Information Act of 1992, I may legally speak to another health care provider or a member of your family about you without your prior consent, but will do so only when the situation is an emergency. You may direct me to share information with whomever you choose, and you can change your mind and revoke that permission at any time. You may request anyone you wish to attend a session with you. You are also protected under the provisions of the Federal Health Insurance Portability and Accountability Act (HIPAA). This law insures the confidentiality of all electronic transmission of information about you. Whenever I transmit information about you electronically it will be done with special safeguards to insure confidentiality. If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your or my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be electronically filed in an encrypted file as part of your treatment record. In all email correspondence I will be mindful of the confidentiality of the content. If I feel the issue is better discussed in person or by phone due to confidentiality issues I will suggest we make an appointment to speak.

MINOR AGREEMENT I understand that the normal procedure for discussing issues that are in my child’s/children’s therapy will be joint sessions including my child/children, the therapist, and me and perhaps other appropriate adults. If I believe there are significant health or safety issues, I will contact the therapist and attempt to arrange a session without my child/children present.

Similarly, when the therapist determines that there are significant issues that should be discussed with parents, every effort will be made to schedule a session involving the parents and the child/children. I understand that if information becomes known to the therapist and has a significant bearing on the child’s/children’s well-being, the therapist will work with the person providing the information to ensure that both parents are aware of it. In other words, the therapist will not divulge secrets except as mandated by law, but may encourage the individual who has the information to disclose it for therapy to continue effectively.

The following are legal exceptions to your right of confidentiality. I would inform you of any time when I think I will have to put these into effect.

1. If I have good reason to believe that you or child will harm another person, I must attempt to inform that person and warn them of your intentions. I must also contact the police and ask them to protect your intended victim.

2. If I have good reason to believe that you are abusing or neglecting a child or vulnerable adult, or if you give me information about someone else who is doing this, I must inform Child Protective Services within 48 hours and Adult Protective Services immediately.

3. If I believe that you or child is in imminent danger of harming yourself/yourselves, I may legally break confidentiality and call the police or relevant crisis team. I am obligated to do this, and would explore all other options with you before I took this step. If at that point you were unwilling to take steps to guarantee your safety, I would call the crisis team.

4. If you tell me of the behavior of another named health or mental health care provider that informs me that this person has either (a.) engaged in sexual contact with a patient, including yourself or (b.) is impaired from practice in some manner by cognitive, emotional, behavioral, or health problems, then the law requires me to report this to their licensing board at the TX Dept. of Health. I would inform you before taking this step.

If you are my client and a health care provider, however, your confidentiality remains protected under the law from this kind of reporting.

Record-keeping. I keep very brief records, noting only that you have been here, what interventions happened in session, and the topics we discussed. If you prefer that I keep no records, you must give me a written request to this effect for your file and I will only note that you attended treatment in the record. Under the provisions of the Health Care Information Act of 1992, you have the right to a copy of your file at any time. You have the right to request that I correct any errors in your file. You have the right to request that I make a copy of your file available to any other health care provider at your written request. I maintain your records in a secure location and they are not open to other persons.

Parent Signature*