• MM slash DD slash YYYY
  • Prior Mental Health Care

  • First Mental Health Care
  • Most Recent Care

    An adult client or an adult guardian who has assumed the cost of treatment. Payment is expected at the time of service.
  • (# of siblings, marriages/significant relationships, children, impacting events, e.g. moves, developmental changes, sexual/physical/emotional abuse, trauma, divorce.)
  • (Current & past medications & dosages, illnesses, etc.)
  • (Client or Family)
  • (Arrests, violations, warnings, Conditional Discharge, DWIs, probation (past or present), guardianships, durable power of attorney, living wills, JSOs, DCYF involvement, etc.)
  • Youth History Section

    (to be completed by parent or guardian of minor client)
  • MM slash DD slash YYYY
  • Pregnancy and Birth History

  • Developmental History

  • At what age did your child?
  • Home and Community

  • (please note whether living in or outside of the home)
  • (i.e. Adhd, learning disabilities, depression alcoholism, anxiety) or neurological disorders (i.e. seizures, Tourettes, autism)
  • Prior Psychological Evaluations/Treatment

  • Other Contacts

    Other care professionals you are currently undergoing treatment with (e.g. other medical professionals such as acupuncturist, chiropractor, medical specialists, etc.)
  • This field is for validation purposes and should be left unchanged.

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