ADOLESCENT NEW PATIENT PAPERWORK

Adolescent Form 01/18 Demographics

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    Demographic Verification

Adolescent Form 02/18 Intake Procedures

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    Intake Procedures

Adolescent Form 03/18 Freedom of Choice

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    Freedom of Choice Statement

Adolescent Form 04/18 Financial Responsibility

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    Financial Responsibility & Release

Adolescent Form 05/18 Parental Consent

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    Guardian/Parent Consent

  • Consent of both parents/guardians may be required for treatment

    Documentation may be required.

Adolescent Form 06/18 Informed Consent

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    Informed Consent

Adolescent Form 07/18 PHI Disclosure

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    Protected Health Information (PHI) Disclosure

Adolescent Form 08/18 No Show Cancellation Policy

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    Cancellation/No-Show Policy

Adolescent Form 10/18 Overweight Risk Assessment

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    Child Overweight Risk Assessment

  • Instructions for this form.

    Through these questions, please read the full question carefully. After reading the question, if you feel that the answer is "Yes" please indicate your answer with a 1 in the field. If you feel that the answer is "No" please indicate your answer with a 0 in the field.
  • Interpretation:

    0-2 ‘Yes’ answers:
    Your child’s overweight risk is low. A child’s overweight risk can change as their eating and activity habits change. Learn the overweight risk factors and encourage changes of your child develops any risk factors.

    3-4 ‘Yes’ answers:
    Your child’s overweight risk is moderate. You can help your child lower their overweight risk by slowly introducing them to a more active lifestyle and healthier eating habits.

    5+ ‘Yes’ answers:
    Your child’s overweight risk is high. Help your child lower their overweight risk by slowly introducing them to a more active lifestyle and healthier eating habits.

    These assessments should be used for education about medical conditions only and are not for providing medical diagnosis. Only a health care professional can diagnose and recommend treatment. You are advised to promptly check with a physician if a medical condition exists or is suspected.

Adolescent Form 12/18 SCARED

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    Screen for Child Anxiety Related Disorders

  • Directions
    Below is a list of statements that describe how people feel. Read each statement carefully and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for your child. Then for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.

Adolescent Form 13/18 ODD Behavioral Rating Scale

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    ODD Behavioral Rating Scale

Adolescent Form 14/18 Severity Measure for Depression

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    Severity Measure for Depression

  • Instructions for this form.

    How often have you been bothered by each of the following symptoms during the past 7 days? For each symptom please indicate...

    0 for "Not at All"
    1 for "Several Days"
    2 for "More than half the days"
    3 for "Nearly every day"

Adolescent Form 16/18 DAST-10 Questionnaire

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    DAST-10 Questionnaire

  • The following is a list of questions concerning information about your potential involvement with drugs, excluding alcohol and tobacco, during the past 12 months. When the words “drug abuse” are used, they mean the use of prescribed or over-the-counter medications/drugs in excess of the directions and any non-medical use of drugs. The various classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquillizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD) or narcotics (e.g., heroin). Remember that the questions do not include alcohol or tobacco. If you have difficulty with a statement, then choose the response that is mostly right. You may choose to answer or not answer any of the questions in this section.
  • Instructions for this form.

    Through these questions, please read the full question carefully. After reading the question, if you feel that the answer is "Yes" please indicate your answer with a 1 in the field. If you feel that the answer is "No" please indicate your answer with a 0 in the field.

Adolescent Form 17/18 Mood Disorders

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    Mood Disorders

  • Has there ever been a period of time when you were not your usual self and…

Adolescent Form 18/18 Encounter Form

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    Encounter Form