Patient Name

Patient Age

E-mail Address

Phone Number

What insurance do you have?

Current Medications

The parents of the child are? The parents of the child are?MarriedDivorcedNever-Merried

Which parent has medical decision making?

Do both parents consent to this child being treated by a Psychiatrist?

Are there any legal procedings involving the new patient?

Is there a history of drug use/abuse?

Please list the reason/s that we will be seeing the patient (anxiety, depression, eating disorder, etc...) and any additional information.