ACM Psychiatric Consultants, LLC.
Ardis C. Martin, M.D.
4740 Flintridge Drive
Suite 214
Colorado Springs, CO 80918
Fax: 719-344-2311
www.acmpsych.com
Comprehensive Child and Adolescent Intake Form
CONTACT INFORMATION AND PERSONAL DATA
Today’s Date: _______________
Patient’s Name:
Date of Birth: ______________
Last
First
Ethnicity/Race: ______________
Middle
_________ Age: ____ SSN: ____- ___ - ___ Gender: M
Home Address:
City:
State:
F___
Zip: _______
Home Phone:
Work Phone:
Fax: _____________
Mobile Phone:
E-mail address: __________________________________
At what telephone number may messages be left?____________________________________________
Referral Source:
Name: ________________________________________ Phone: _______________________________
Address: ______________________________________ Fax: _________________________________
Sources of Information:
Person/s completing this form: Relationship:
Patient’s legal guardian(s):
___ Married parents
___ Single parent/sole custody
___ Divorced parents; joint custody and decision making
___ Divorced parents; sole custody of ___Mother ___Father
___ Foster child; DSS
___ Other:
If applicable, the Parenting plan/Custody Decree has been included with the packet: ___Yes ___ No
Parent/Guardian #1 __________________________________________________________________
Relationship to patient: _____biological _____adoptive _____ foster _____ step _____other: ____
Parent/Guardian #2 __________________________________________________________________
Relationship to patient: _____biological _____adoptive _____ foster _____ step _____other: ____
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Birth Mother, if different________________________________________________________________
Birth Father, if different_________________________________________________________________
Other Parental figures: _____Step-Parent(s)________________________________________________
_____Foster Parent(s)______________________________________________
_____Grandparent(s)_______________________________________________
INSURANCE INFORMATION
Insurance Carrier:
Plan Name: __________________
EMERGENCY CONTACT INFORMATION
Emergency Contact Name:
Phone: _______________________
Relationship to patient: _________________________________________________________________
Name and telephone number of patient’s primary care physician_________________________________
Name and telephone number of pharmacy: ________________________________________________
Reason(s) you are bringing your child in for an evaluation:
Chief Complaints (Main Concerns You Would Like Addressed – Please provide a brief description of the
problem):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Problem Areas: (Please check all that apply and explain below)
___Behavioral Problems ___Legal Problems ___Social Problems ___Emotional Problems ___ School Problems
History of abuse or neglect (emotional, verbal, physical, sexual):
Recent Family Stressors?
YES or NO
If YES, please describe: ________________________________________________________________
____________________________________________________________________________________
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Past Treatment or Evaluations for these Problems?
YES or NO
If YES, please describe (Provider’s name, Type of Evaluation, i.e. Psychiatric vs. Psychological Testing,
etc.)
____________________________________________________________________________________
Developmental History:
Any problems during pregnancy or birth complications?
YES or NO
Any in utero exposure to substances, alcohol, nicotine, medications, x-rays, or caffeine?
YES or NO
If YES, please describe:________________________________________________________________
____________________________________________________________________________________
Did your child/adolescent meet developmental milestones (crawling, walking, talking, potty training, etc.)
on time?
YES or NO
If NO, please list delays (age):
___________________________________________________________________________ ________
____________________________________________________________________________________
Is your child/adolescent currently taking medications for psychiatric or emotional problems?
YES or NO
If YES, please list medications with dosages and provider’s name below:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Has your child/adolescent previously taken medications for psychiatric or emotional problems?
YES or NO
If YES, please list past medications, dosages, side effects (if any) below:
____________________________________________________________________________________
____________________________________________________________________________________
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Has your child/adolescent ever been hospitalized for psychiatric reasons?
YES or NO
If YES, please list when, where, and duration of each hospitalization:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Has your child/adolescent been in treatment with a psychiatrist and/or therapist previously? YES or NO
If YES, please list who he/she was seeing:
____________________________________________________________________________________
Is your child/adolescent currently seeing a therapist? YES or NO
If YES, please list who he/she is seeing:
____________________________________________________________________________________
MEDICAL HISTORY
Please list any MEDICAL PROBLEMS:
____________________________________________________________________________________
____________________________________________________________________________________
Is your child/adolescent taking medications for medical purposes (non psychiatric medications)?
YES or NO
If YES, please list medications he/she is taking below:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Please list any DRUG ALLERGIES (and reaction):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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Please list any SURGERIES (with dates):
____________________________________________________________________________________
____________________________________________________________________________________
Family Psychiatric History:
Has any blood relative (Parents/Grandparents/Siblings/Aunts/Uncles/Cousins) been diagnosed or treated
for a psychiatric illness? Please circle all that apply
Depression
Obsessive Compulsive Disorder
Generalized Anxiety
Bipolar Disorder
ADHD
Schizophrenia
Eating Disorders
Substance Abuse
Alcoholism
Other
Is there a history of any attempted or completed suicides in the family?
If YES, Who
____________________________________________________________________________________
Are there any medical illnesses that run in the family? Please circle all that apply
Seizures
Thyroid Problems
Diabetes
Anemia
Arrhythmias
Cancer
Heart Attacks
Strokes
Migraines
Other
SOCIAL HISTORY:
Who is currently living in the home (parents, siblings, grandparents, significant others).
Name
Gender
Age
Relationship
Nature of relationship to
child/adolescent
What grade is your child/adolescent in?
____________________________________________________________________________________
Does your child/adolescent have an IEP? YES or NO.
Is your child/adolescent in a Special Education Program? YES or NO.
What school does your child/adolescent attend?
____________________________________________________________________________________
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Academic Functioning
Child/Adolescent is performing: ___ at
___ at
___ at
___above ___below
___above ___below
___above ___below
grade level
family expectations
patient’s own expectations.
Does your child/adolescent have a specific difficulty with: ___writing
___reading
___math
Parent(s)/Guardian(s) Occupation/Education:
____________________________________________________________________________________
____________________________________________________________________________________
Any out of home placements (foster care, residential treatment facility, living with another relative or
parent/guardian)?
YES or NO
If YES, please list type of placement and dates.
____________________________________________________________________________________
Has your child/adolescent ever had any legal problems (probation, youth corrections, etc.)
YES or NO
If, YES, please list charges, dates of probation, probation officer name if currently on probation, and any
jail time (PYC, Spring Creek, DYC).
____________________________________________________________________________________
____________________________________________________________________________________
SUBSTANCE ABUSE HISTORY:
Does your child/adolescent drink alcohol? YES NO
Does your child/adolescent currently use any illicit drugs (including marijuana)?
Has your child/adolescent previously used illicit drugs? YES NO
YES
NO
If you answered YES, please describe the type and amount of use:
____________________________________________________________________________________
____________________________________________________________________________________
Has your child/adolescent ever participated in an alcohol or drug treatment program? YES or NO
If you answered YES, please describe where and length of treatment:
____________________________________________________________________________________
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Is there any additional information that you feel would be important for Dr. Martin to
know? Please provide:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
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