Pre Assesment Form

Pre-Admission Form

"*" indicates required fields

Parent/Family Information

DateContact

Parent 1 Name*

First Last

Parent Phone Number*

Parent Email*

Parent 1 Occupation

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent 2 Name

Parent Phone Number

Parent Email

Parent 2 Occupation

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parents current marital status

If step-parents are involved, please include their contact information

How many siblings does the adolescent have? Do they live in the home? If not, what is their current status?

Client Information

Child's Legal First & Last Name (to verify insurance benefits)*

First Last

Child’s DOB*

Primary Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Referral Information

Who referred you?

Reason for referral

Reason for referral: What made you call for treatment at this time? Chief Complaint and Symptoms (i.e. issues at home or school, symptoms, mood changes, changes in behavior etc.) For most families, the presenting issues have been in existence for some time so please describe what is happening now to make you seek out residential treatment.

Placement Information

Does your child have any formal diagnoses? If so, what are they and who initially provided the diagnoses?

Does your child exhibit any signs of anxiety, depression, mood swings etc? If yes, please describe the specific symptoms.

Is your child currently expressing suicidal or homicidal thoughts? Y or N. If yes, please describe.

If so, have they ever communicated having a plan for suicide or any previous suicide attempts? Please describe all attempts including dates, suicidal behavior, and what the follow up was.

Does you child ever engage in self harming behaviors (cutting, head-banging, scratching, bruising, etc)? If so, where on the body and how frequently?

Are you aware of any substance abuse/use issues? If so, age of suspected onset, use pattern, last suspected date of use.

Describe your child’s treatment history (i.e individual therapy, family therapy, previous or current hospitalizations, IOP/PHP/RTC history)including dates, reason for admissions, length of stay:

May we contact current treatment providers?

Psychological History

Please describe any major events your child has struggled with:

Please describe the way your child handles anger:

Does your child demonstrate aggressive behaviors (physical, verbal, history of fighting, aggression outside of the home setting etc)?

Does your child have a history of running away?

Does your child experience recurrent thoughts or repeated behaviors that they cannot control (i.e. OCD)?

Please describe any risky, aggressive, or inappropriate sexual behaviors (i.e. promiscuity, sexual solicitation, unprotected sex):

Does your child have any issues related to eating? Have you noticed a change in eating patterns recently? If so, has this contributed to any change in weight?

Have they ever struggled with disordered eating or have a formal ED diagnoses?

Does your child currently have any legal issues?

Does your child have an autism diagnoses?

Has your child ever had formal psychological testing by a psychologist? (this usually takes up to 6 hours and you pay for it separately, or the school psychologist does it.)

Family History

Is there a family history of mental health issues?

Is there a family history of substance abuse?

Education Information

Highest grade level completed:

Is your child currently attending school? If school refusal, for how long?

Previous school functioning:

Has your child been assessed for learning disabilities or have a 504 or IEP?

Medical Information

Does your child have any medical issues (i.e. diabetes)?

Does your child have any allergies?

Is your child currently on medications?

Please list previous medications:

What is your child’s current height and weight?

Important Contact Information

Pediatrician Name

Pediatrician Number

Pediatrician Email

Outpatient Psychiatrist Name

Outpatient Psychiatrist Number

Outpatient Psychiatrist Email

Therapist (current) Name

Therapist (current) Number

Therapist (current) Email

Previous Primary Treatment Providers Name

Previous Primary Treatment Providers Name Number

Previous Primary Treatment Providers Email

Previous Hospitalizations Name

Previous Hospitalizations Number

Previous Hospitalizations Email

Previous Treatment Type (Residential Treatment)

Wilderness Therapy Programs/PHP/IOP)

Previous Treatment Primary Therapist Name

Previous Treatment Primary Therapist Number

Previous Treatment Primary Therapist Email

Insurance Information

Insurance Company Name

Insurance Company Phone Number

Policy #

Group #

Subscriber Name:

Subscriber DOB

Secondary Insurance Information (if applicable):

Insurance Company Name

Insurance Company Phone Number

Policy #

Group #

Subscriber Name:

Subscriber DOB

Name

First Last

Pre Assesment Form

Pre-Admission Form

Parent/Family Information

Client Information

Referral Information

Placement Information

Psychological History

Family History

Education Information

Medical Information

Important Contact Information

Insurance Information

Secondary Insurance Information (if applicable):

Family, Passion, and Empowerment