Minor Intake – Brain Health USA

Patients Name *

First

Last

Date Of Birth

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Please upload Copy of Guardian’s ID (Driver License/Passport)

Click or drag a file to this area to upload.

Do you have secondary insurance?

Yes
No

Pharmacy name

Pharmacy address

Address Line 1

Address Line 2

City

State

Zip Code

Are you seeking therapy or psychiatry? *

Psychiatry (Medication management)
Therapy ( No medication)
both

Do you attend the regional center for autism or intellectual disability? *

YES
NO

Intake Questions

 Please type in Patient's current Height

5:11

 Please type in Patient's current Weight.

190

What is your main reason for seeking mental health services?

Evaluation/Consultation
Medication Management

Is the patient currently taking medication? *

YES
NO

Have the patient ever been hospitalized for any psychiatric reasons?

YES
NO

Does the patient have any medication Allergies?

YES
NO

Does the patient ever had any Surgery?

YES
NO

What would be your treatment goal for the Patient? *

To get an evaluation and anger management

Score the below Questions accordingly using (Never, Sometimes, Often)

Does the Patient

Complains of aches/pains

Never
Sometimes
Often

Spends more time alone

Never
Sometimes
Often

Tires easily, has little energy

Never
Sometimes
Often

Fidgety, unable to sit still

Never
Sometimes
Often

Has trouble with a teacher

Never
Sometimes
Often

Less interested in school

Never
Sometimes
Often

Acts as if driven by a motor

Never
Sometimes
Often

Daydreams too much

Never
Sometimes
Often

Gets distracted easily

Never
Sometimes
Often

. Is afraid of new situations

Never
Sometimes
Often

Feels sad, unhappy

Never
Sometimes
Often

Is irritable, angry

Never
Sometimes
Often

Feels hopeless

Never
Sometimes
Often

Has trouble concentrating

Never
Sometimes
Often

Less interest in friends

Never
Sometimes
Often

Fights with others

Never
Sometimes
Often

Absent from school

Never
Sometimes
Often

School grades dropping

Never
Sometimes
Often

Is down on him or herself

Never
Sometimes
Often

Visits doctor with doctor finding nothing wrong

Never
Sometimes
Often

Has trouble sleeping

Never
Sometimes
Often

Worries a lot

Never
Sometimes
Often

Wants to be with you more than before

Never
Sometimes
Often

Feels he or she is bad

Never
Sometimes
Often

Takes unnecessary risks

Never
Sometimes
Often

Gets hurt

Never
Sometimes
Often

Seems to be having less fun

Never
Sometimes
Often

Acts younger than children his or her age

Never
Sometimes
Often

Does not listen to rules

Never
Sometimes
Often

Does not show feelings

Never
Sometimes
Often

Does not understand other people’s feelings

Never
Sometimes
Often

Teases others

Never
Sometimes
Often

Blames others for his or her troubles

Never
Sometimes
Often

Takes things that do not belong to him or her

Never
Sometimes
Often

Refuses to share

Never
Sometimes
Often

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