Practice Form

Complete this behavioral health history as detailed as possible. This document is used to complete a prior authorization with your insurance company. Your insurance will want to ensure that your daughter meets medical necessity for inpatient treatment. An incomplete, inaccurate or minor mental health clinical history will delay the admission process with your insurance company.
Note: It is possible to save this form and return to finish it at a later date. Simply scroll to the bottom and hit "save and continue later." After clicking the button, you will receive a custom link to your form and the option of receiving that link via email. Links to saved forms are valid for 30 days.
Referred To Trinity Teen Solutions By:*
Would Admission To TTS Be:
THINGS YOU WILL NEED ON HAND TO COMPLETE THIS FORM:
1. Patient's and parents' SSN
2. Insurance card
3. Current list of medications
4. Past list of medications
5. List of places, dates of mental health treatments
6. Medical and Psychiatric providers: Name, address, phone, fax information
IN ORDER TO BE CONSIDERED FOR TREATMENT

PAST CLINICAL RECORDS FROM MENTAL HEALTH TREATMENTS NEED TO BE SUBMITTED FOR CONSIDERATION BY OUR TREATMENT TEAM

PRIOR TO ADMISSION NEED TO SUBMIT
1. Past mental health clinical records
2. History and/or physical no older than 7 days before admission date
3. Copy of front and back of insurance card
4. Current immunization record
5. Custody paper work
Patient Information Section
Patient's First Name*
Patient's Middle Name
Patient's Last Name*
Refer To Patient As:
Nickname, Preferred Name
Date Of Birth*
MM
DD
YYYY
Age*
Sex*
Physical Address*
Street Address Address Line 2 City State ZIP Code
Mailing Address (if different)
Street Address Address Line 2 City State ZIP Code
Social Security Number*
Allergies*
Religion*
Preferred Language*
Race*
Ethnicity*
Birth Order*
Multiple Birth*
Place Of Birth (City, State)*
Eye Color*
Hair Color*
Skin Color*
Height*
Weight*
Shoe Size*
Pant Size*
Bra Size*
Scars/Tattoos*
Piercings*

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Emergency Information
Who would you like us to contact if we cannot get a hold of parents
First Contact
Cannot be who child lives with
First Name*
Last Name*
Relationship*
Email*
Home Phone*
Work Phone*
Cell Phone*
Second Contact
Cannot be who child lives with
First Name*
Last Name*
Relationship*
Email*
Home Phone*
Work Phone*
Cell Phone*
Primary Insurance Information
Primary Insured Name (first/last)*
Social Security Number*
Date Of Birth*
Date Format: MM slash DD slash YYYY
Relationship*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Employer*
Insurance Company*
Insurance Company Phone Number*
Policy ID*
Group ID*
Would you like to enter secondary insurance?*
- Yes
- No
Secondary Insurance Information
Primary Insured Name (first/last)
Social Security Number
Date Of Birth
Date Format: MM slash DD slash YYYY
Relationship
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Employer
Insurance Company
Insurance Company Phone
Policy ID
Group ID

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Current Mental Health and Behavioral History
PATIENTS WILL BE ADMITTED TO THE BEHAVIORAL HEALTH UNIT WHEN HER BEHAVIORAL HEALTH NEEDS MEET DIAGNOSTIC CRITERIA AND ARE APPROPRIATE FOR DIAGNOSIS AND TREATMENT IN AN INPATIENT RESIDENTIAL TREATMENT CENTER, PARTIAL HOSPITALIZATION PROGRAM AND/OR AN INTENSE OUTPATIENT PROGRAM. IN ORDER TO MEET MEDICAL NECESSITY FOR INSURANCE PURPOSES, YOU NEED TO EXPLAIN IN DETAIL HER BEHAVIORS AS ACCURATELY AS POSSIBLE. MINIMAL INFORMATION WILL HINDER INSURANCE REIMBURSEMENT FOR TREATMENT AND ACCEPTANCE INTO TREATMENT.
Provide a narrative timeline of your daughter’s history from birth to the current psychiatric precipitating events that are leading up to this admission. Make sure to provide dates and how old she was in your timeline.*
Current Psychiatric Diagnosis (Include Clinical Records to prove)*
Upload Clinical Records
Accepted file types: pdf.
PDF only
Placements Over the Last Year*
Current locations patient has been in over the last year Admit date Reason Discharge date Reason for going to another facility or discharge

Please include hospitals, inpatient psychiatric facilities, incarcerations, residential treatment centers, group homes, boarding schools, and any other placements.
Past Mental Health Inpatient Treatment*
Name of Inpatient Facility Admit date Reason Discharge date Reason for going to another facility or discharge
Past Mental Health Outpatient Treatment*
Name of Outpatient Facility/Provider Treatment start date Reason Treatment end date Reason for stopping treatement Did it help? Y/N
List Current Prescription Medications*
Name New (Yes/No) Dose Frequency Route First Dose - Date Last Dose - Date Reason for Medication Helpful (Yes/No)
Discontinued Medications*
Name Dose Date started Date stopped Reason stopped
List Current Over-the-Counter Medications*
Name New (Yes/No) Dose Frequency Route First Dose - Date Last Dose - Date Reason for Medication Helpful (Yes/No)
List Current Vitamins, Supplements, Herbals, and Other*
Name New (Yes/No) Dose Frequency Route First Dose - Date Last Dose - Date Reason for Medication Helpful (Yes/No)
Psychiatrist Information*
Name Address Phone Fax Date of last psychiatrist visit Reason for the last visit Is psychiatrist aware of patient placement? Y/N Is psychiatrist referring patient to residential treatment? Y/N
Therapist/Counselor Information*
Name Address Phone Fax Date of last counseling visit Reason for the last visit Is psychiatrist aware of patient placement? Y/N Is psychiatrist referring patient to residential treatment? Y/N
Describe patient's timeline of behaviors over the last year that are precipitating you seeking inpatient treatment, especially ways she is a risk to herself or others. (This information is especially important for your insurance company.)*
Describe anything that has impeded her previous treatment(s) or intervention(s) in your opinion:*
List her strengths:*
List her weaknesses:*
What does she do for leisure and recreational activities?*
Student Developmental History
Problems During Mother's Pregnancy*
Check All That Apply
- none
- high blood presssure
- kidney infection
- German measles
- emotional stress
- bleeding
- alcohol use
- drug use
- cigarette use
- other
If other, describe:
Birth*
- Normal delivery
- Difficult delivery
- Cesarean delivery
- Complications
Describe:*
Birth weight*
Infancy*
- feeding problems
- sleep problems
- toilet training problems
- none of the above
Childhood Health*
- Chickenpox
- German measles
- red measles
- rheumatic fever
- whooping cough
- scarlet fever
- autism
- allergies
- significant injuries
- lead poisoning
- mumps
- diptheria
- poliomyelitis
- pneumonia
- tuberculosis
- mental retardation
- asthma
- ear infections
- chronic, serious health problems
- none of the above
Designate the age of when she suffered from these illnesses as well as any allergies and significant injuries.*
Delayed developmental milestones*
- Rolling Over
- Sitting
- Standing
- Walking
- Sleeping Alone
- Speaking Words
- Speaking Sentences
- Controlling Bowels
- Controlling Bladder
- Feeding Self
- Dressing Self
- Tolerating Separation
- Playing Cooperatively
- Riding Tricycle
- Riding Bicycle
- Disobedient
- Engaging Peers
- Other
- None of the above
(check only those milestones that did not occur at expected age)
Describe Other:
Intellectual/Academic Functioning*
- Normal Intelligence
- High Intelligence
- Learning Problems
- Underachieving
- Authority Conflicts
- Attention Problems
- Mild Retardation
- Moderate Retardation
- Severe Retardation
Social Interaction*
- Normal social Interaction
- Isolates Self
- Very Shy
- Alienates Self
- Inappropriate Sex Play
- Dominates Others
- Associates With Acting-out Peers
- Other
Describe Other:
Childhood Emotional Behavioral Problems*
(Behavior 0-11 years of age, check all that apply)
- Drug Use
- Alcohol Abuse
- Chronic Lying
- Stealing
- Violent Temper
- Fire-Setting
- Hyperactive
- Immature
- Bizarre Behavior
- Animal Cruelty
- Assault Others
- Lack of Attachment
- Repeat Words Of Others
- Not Trustworthy
- Hostile/Angry Mood
- Indecisive
- Self-Injurious Threats
- Frequently Tearful
- Frequently Daydreams
- Distrustful
- Extreme Worrier
- Self-Injurious Acts
- Impulsive
- Easily Distracted
- Poor Concentration
- Often Sad
- Breaks Things
- Other
- None of the above
Describe Other:
Educational History
Current Grade*
GPA*
Last Grade Completed*
Favorite Subject*
Least Favorite Subject*
Name of School*
School Address*
Street Address Address Line 2 City State ZIP Code
School's Phone*
Describe Academic Performance*
Grade School*
Middle School*
High School*
Mark Difficulties In School*
- Contraband
- Expelled
- Fighting
- Suspensions
- Failing
- Skipping
- None of the above
Describe Special Education Needs*
Cognitive Ability
What age do you think she is emotionally?*
What age do you think she is intellectually?*
Describe her ability to communicate with others:*
Describe her ability to understand her environment:*
Describe her ability to be employed:*
What is her IQ?*

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Substance Abuse
For each substance, indication Yes or No if patient has a history of substance abuse. If yes, complete the information. *Family history: list anyone biologically related to patient who uses or used this substance.
Methamphetamine*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Cocaine*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Heroin*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
LSD/Hallucinogens*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Marijuana*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Painkillers (not as prescribed)*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Stimulants*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Methadone*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Tranquilizers/Sleeping pills*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Alcohol*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Ecstasy*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Cigarettes/Pipe/Cigars/E-Cigs*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Caffeinated beverages*
History of use? Y/N How used Age of 1st use How long used Frequency Date of last use Family history
Other (list each substance)
Substance How used Age of 1st use How long used Frequency Date of last use Family history
Pain
Does she complain of any kind of pain?*
- Yes
- No
Where does she hurt?*
What is the intensity on a scale of 1-10 (with 10 being severe?)*
When did the pain start?*
Has she had pain in the last month?*
- Yes
- No
Has she been in pain more than 6 months?*
- Yes
- No

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Medical History
Cardiovascular
Primary Care Physician*
Name Address Phone Fax Is Primary Care Physician aware of patient placement? Y/N
Date of last doctor visit*
Reason for last visit*
Chest Pain*
Current Issue Y/N Past Issue Y/N Comments
Heart Murmur*
Current Issue Y/N Past Issue Y/N Comments
High/low blood pressure*
Current Issue Y/N Past Issue Y/N Comments
Rheumatic heart disease*
Current Issue Y/N Past Issue Y/N Comments
Syncope/Passing out issues*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other cardiovascular condition Current Issue Y/N Past Issue Y/N Comments
Ear/Nose/Throat
Date of last hearing screening*
Reason for last screening*
Difficulty swallowing medications*
Current Issue Y/N Past Issue Y/N Comments
Drainage*
Current Issue Y/N Past Issue Y/N Comments
Ear Infections*
Current Issue Y/N Past Issue Y/N Comments
Head Cold*
Current Issue Y/N Past Issue Y/N Comments
Hearing Problems*
Current Issue Y/N Past Issue Y/N Comments
Nasal Allergies*
Current Issue Y/N Past Issue Y/N Comments
Nose Bleeds*
Current Issue Y/N Past Issue Y/N Comments
Pain*
Current Issue Y/N Past Issue Y/N Comments
Redness of throat*
Current Issue Y/N Past Issue Y/N Comments
Ringing in ears*
Current Issue Y/N Past Issue Y/N Comments
Sore throat*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Ear/Nose/Throat issues Current Issue Y/N Past Issue Y/N Comments
Gastrointestinal
Diabetes*
- Yes
- No
Insulin*
- Yes
- No
Dietary Preferences*
- Vegetarian
- Vegan
Special Diet for Medical Reasons (explain)*
Food allergies*
Blood in bowel movement*
Current Issue Y/N Past Issue Y/N Comments
Constipation*
Current Issue Y/N Past Issue Y/N Comments
Diarrhea*
Current Issue Y/N Past Issue Y/N Comments
Frequent heartburn*
Current Issue Y/N Past Issue Y/N Comments
Hemorrhoids*
Current Issue Y/N Past Issue Y/N Comments
Hepatitis*
Current Issue Y/N Past Issue Y/N Comments
Nausea/vomiting*
Current Issue Y/N Past Issue Y/N Comments
Recent weight loss*
Current Issue Y/N Past Issue Y/N Comments
Recent weight gain*
Current Issue Y/N Past Issue Y/N Comments
Ulcers*
Current Issue Y/N Past Issue Y/N Comments
Crohns Disease*
Current Issue Y/N Past Issue Y/N Comments
Use of laxatives*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Gastrointestinal Issues Current Issue Y/N Past Issue Y/N Comments
Head/Neurological
Concussion/Knocked out*
Current Issue Y/N Past Issue Y/N Comments
Disorientation*
Current Issue Y/N Past Issue Y/N Comments
Dizzy*
Current Issue Y/N Past Issue Y/N Comments
Fainting*
Current Issue Y/N Past Issue Y/N Comments
Frequent headache*
Current Issue Y/N Past Issue Y/N Comments
Lice*
Current Issue Y/N Past Issue Y/N Comments
Numbness/tingling*
Current Issue Y/N Past Issue Y/N EEG date Comments
Paralysis*
Current Issue Y/N Past Issue Y/N Comments
Seizure*
Current Issue Y/N Past Issue Y/N Age of onset Date of last seizure Comments
Other (specify)
Other Head/Neurology Issues Current Issue Y/N Past Issue Y/N Comments
Musculoskeletal
Ankle sprain*
Current Issue Y/N Past Issue Y/N Comments
Back pain*
Current Issue Y/N Past Issue Y/N Comments
Broken bones*
Current Issue Y/N Past Issue Y/N Comments
Dislocation*
Current Issue Y/N Past Issue Y/N Comments
Impaired mobility*
Current Issue Y/N Past Issue Y/N Comments
Joint pain*
Current Issue Y/N Past Issue Y/N Comments
Rheumatoid Arthritis*
Current Issue Y/N Past Issue Y/N Comments
Joint swelling*
Current Issue Y/N Past Issue Y/N Comments
Scoliosis*
Current Issue Y/N Past Issue Y/N Comments
Exercise Regularly*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Musculoskeletal Issues Current Issue Y/N Past Issue Y/N Comments
Does she have any physical limitations? Is she at risk of falling down, if yes explain:*
Genitourinary
Blood in urine*
Current Issue Y/N Past Issue Y/N Comments
Frequent urination*
Current Issue Y/N Past Issue Y/N Comments
Pain with urination*
Current Issue Y/N Past Issue Y/N Comments
Urinary tract infection*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Genitourinary Issues Current Issue Y/N Past Issue Y/N Comments
Reproductive - Female
Gynecologist Information*
Name Address Phone Fax Date of last gynecological exam Reason for the last exam
Sexual History*
- heterosexual orientation
- homosexual orientation
- bisexual orientation
- currently sexually active
- history of promiscuity
- history of unsafe sex
Breast lumps*
Current Issue Y/N Past Issue Y/N Comments
Sexually active*
Current Issue Y/N Past Issue Y/N Comments
Condum use*
Current Issue Y/N Past Issue Y/N Comments
Sexual abuse victim*
Current Issue Y/N Past Issue Y/N Comments
Sexually Transmitted Diseases (specify)*
Specify Current Issue Y/N Past Issue Y/N Comments
Abortions*
Current Issue Y/N Past Issue Y/N Comments
Birth control use*
Current Issue Y/N Past Issue Y/N Comments
Menses, specify*
Age began Number of days between menses Last menstrual period Length of bleeding Current Issue Y/N Past Issue Y/N Comments
Miscarriages*
Current Issue Y/N Past Issue Y/N Comments
Pain with menses*
Current Issue Y/N Past Issue Y/N Comments
Pregnancies*
Current Issue Y/N Past Issue Y/N Comments
Vaginal discharge*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Reproductive Issues Current Issue Y/N Past Issue Y/N Comments
Respiratory
Asthma*
Current Issue Y/N Past Issue Y/N Comments
Coughing up blood*
Current Issue Y/N Past Issue Y/N Comments
Night sweats*
Current Issue Y/N Past Issue Y/N Comments
Persistent cough*
Current Issue Y/N Past Issue Y/N Comments
Pneumonia*
Current Issue Y/N Past Issue Y/N Comments
Shortness of Breath*
Current Issue Y/N Past Issue Y/N Comments
Tuberculosis infection, disease, and/or treatment*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Respiratory Issues Current Issue Y/N Past Issue Y/N Comments
Skin
Acne*
Current Issue Y/N Past Issue Y/N Comments
Athlete's Foot*
Current Issue Y/N Past Issue Y/N Comments
Eczema*
Current Issue Y/N Past Issue Y/N Comments
Hives*
Current Issue Y/N Past Issue Y/N Comments
Impetigo*
Current Issue Y/N Past Issue Y/N Comments
Jaundice*
Current Issue Y/N Past Issue Y/N Comments
Rash*
Current Issue Y/N Past Issue Y/N Comments
Psoriasis*
Current Issue Y/N Past Issue Y/N Comments
Scars*
Current Issue Y/N Past Issue Y/N Comments
Sores*
Current Issue Y/N Past Issue Y/N Comments
Warts*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Skin Issues Current Issue Y/N Past Issue Y/N Comments
Sleep Patterns
Difficulty falling asleep*
Current Issue Y/N Past Issue Y/N Comments
Erratic patterns*
Current Issue Y/N Past Issue Y/N Comments
Frequent waking at night*
Current Issue Y/N Past Issue Y/N Comments
Insomnia*
Current Issue Y/N Past Issue Y/N Comments
Nightmares*
Current Issue Y/N Past Issue Y/N Comments
Enuresis*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Sleep Pattern Issues Current Issue Y/N Past Issue Y/N Comments
Miscellaneous
History of blood transfusions*
Current Issue Y/N Past Issue Y/N Comments
AIDS*
Current Issue Y/N Past Issue Y/N Comments
HIV Positive*
Current Issue Y/N Past Issue Y/N Comments
History of Cancer*
Current Issue Y/N Past Issue Y/N Comments
Leukemia*
Current Issue Y/N Past Issue Y/N Comments
Sickle cell trait/disease*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Issues Current Issue Y/N Past Issue Y/N Comments
Describe any serious hospitalizations or accidents:*
Other chronic or serious health issues:*
Dental/Oral
Dentist/Orthodontist*
Name Address Phone Fax
Date of last dentist visit*
Reason for last visit*
Abnormal Oral Bleeding*
Current Issue Y/N Past Issue Y/N Comments
Braces*
Current Issue Y/N Past Issue Y/N Comments
Bridges/Caps*
Current Issue Y/N Past Issue Y/N Comments
Caries (decay or cavities)*
Current Issue Y/N Past Issue Y/N Comments
Chipped/absent teeth*
Current Issue Y/N Past Issue Y/N Comments
Dentures*
Current Issue Y/N Past Issue Y/N Comments
Partial Plates*
Current Issue Y/N Past Issue Y/N Comments
Pain*
Current Issue Y/N Past Issue Y/N Comments
Retainers*
Current Issue Y/N Past Issue Y/N Comments
Sores*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Dental/Oral issues Current Issue Y/N Past Issue Y/N Comments
Eyes
Optometrist Information*
Name Address Phone Fax
Date of last eye exam*
Reason for last screening*
Wears glasses/contacts*
Current Issue Y/N Past Issue Y/N Comments
Colorblindness*
Current Issue Y/N Past Issue Y/N Comments
Conjunctivitis*
Current Issue Y/N Past Issue Y/N Comments
Double vision*
Current Issue Y/N Past Issue Y/N Comments
Pain*
Current Issue Y/N Past Issue Y/N Comments
Other (specify)
Other Eye Issues Current Issue Y/N Past Issue Y/N Comments

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Discharge Needs and Plan
What do you think are roadblocks to her recovery or treatment?*
What do you think her needs will be on discharge?*
i.e. new school, on-going family therapy
Any family factors that need to be considered for discharge planning?*
What are your goals and expectations for her in treatment?*
I,
Name of person completing form*
First Last
am the
relationship to the patient*
to the patient, attest that the information provided is complete and accurate. No information was omitted or exaggerated in an effort to obtain treatment for the patient. I/We agree that the information submitted by the Parent/Guardian represents and warrants to TTS that all the information submitted to TTS in connection with the enrollment of the student is true, accurate, complete, and states all information which should reasonably be known by TTS to operate the Program for the benefit of the Student and others. The accuracy and completeness of the information provided by the Parent is a material inducement to TTS's enrollment of the Student in the Program. Failure to provide accurate and complete information shall be a material breach of this Agreement, and TTS shall have the right thereafter to terminate this Agreement.
Signature (filling in your name represents your legal signature and will be treated as such):*
Date*
Date Format: MM slash DD slash YYYY
Email*
Consent
I agree to the privacy policy.

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Current locations patient has been in over the last year	Admit date	Reason	Discharge date	Reason for going to another facility or discharge

Name of Inpatient Facility	Admit date	Reason	Discharge date	Reason for going to another facility or discharge

Name of Outpatient Facility/Provider	Treatment start date	Reason	Treatment end date	Reason for stopping treatement	Did it help? Y/N

Name	New (Yes/No)	Dose	Frequency	Route	First Dose - Date	Last Dose - Date	Reason for Medication	Helpful (Yes/No)

Name	Address	Phone	Fax	Date of last psychiatrist visit	Reason for the last visit	Is psychiatrist aware of patient placement? Y/N	Is psychiatrist referring patient to residential treatment? Y/N

Substance	How used	Age of 1st use	How long used	Frequency	Date of last use	Family history

Other cardiovascular condition	Current Issue Y/N	Past Issue Y/N	Comments

Other Ear/Nose/Throat issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Gastrointestinal Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Head/Neurology Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Musculoskeletal Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Genitourinary Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Reproductive Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Respiratory Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Sleep Pattern Issues	Current Issue Y/N	Past Issue Y/N	Comments

Other Dental/Oral issues	Current Issue Y/N	Past Issue Y/N	Comments

Admissions Application (old)

Step 1 of 14

THINGS YOU WILL NEED ON HAND TO COMPLETE THIS FORM:

IN ORDER TO BE CONSIDERED FOR TREATMENT

PRIOR TO ADMISSION NEED TO SUBMIT

Patient Information Section

Legal Parent/Guardian #1

Legal Parent/Guardian #2

Biological Mother History

Biological Father History

Other Parent/Guardian/Step Parent Information

Other Parent/Guardian/Step Parent Information #1

Other Parent/Guardian/Step Parent #2

Family Of Origin History

Present During Childhood

Additional Family Information

History Family Relationships

Biological Family Past Medical History

Emergency Information

First Contact

Second Contact

Primary Insurance Information

Secondary Insurance Information

Current Mental Health and Behavioral History

Student Developmental History

Educational History

Cognitive Ability

Mood Issues

Sexual Risk Assessment

Aggression/Violence Risk Assessment

Homicidal Risk Assessment

Suicide Self Harm Risk Assessment

Trauma/Abuse/Neglect/Exploitation

Legal Issues

Social Relationships

Eating Disorders/Issues

Cultural/Spiritual/Recreational History

Current Emotional and Behavioral Symptoms She is experiencing

Mental Status

Appearance

Attitude/Mood

Perceptions

Thought Process

Thought Content

Speech

Affect

Substance Abuse

Pain

Medical History

Cardiovascular

Ear/Nose/Throat

Gastrointestinal

Head/Neurological

Musculoskeletal

Genitourinary

Reproductive - Female

Respiratory

Skin

Sleep Patterns

Miscellaneous

Dental/Oral

Eyes

Discharge Needs and Plan

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