Child/Adolescent Intake Western Reserve Psychological Associates, Inc.

Date of Initial Visit______WRPA Therapist______

Minor’s Name ______Birthdate ______SSN:______

Address______Phone:______

Street City State Zip

Male _____ Female _____

Client Status: Employed _____ Full Time Student _____ Part Time Student _____

School currently attending______Grade______Religion______

Father Name ______DOB:______SSN:______

Address if different from the child______

Home Phone______OK to call? Yes _____ No _____ Cell Phone______OK to call? Y_____N_____

Work Phone______OK to call? Yes _____ No _____

Employer______

Employment address ______Street City State Zip

Mother Name ______DOB:______SSN:______

Address if different from the child______

Home phone ______OK to call? Yes _____ No _____ Cell Phone______OK to call? Y_____N_____

Work phone ______OK to call? Yes ____ No _____

Employer ______

Employment address______Street City State Zip

Names and ages of child’s siblings (if applicable): ______

______

Person responsible for deductible, coinsurance, and copayments (This will be the person who brings the child in and also signs the financial responsibility form):______

Address ______

Street City State Zip

Did you contact your insurance company to verify your benefits and let them know you were coming? ______

Deductible/year $______Has it been met?______Copayment/coinsurance/visit $______or _____%

Did you receive an authorization number from your insurance company? Yes_____ No_____

Authorization number ______Number of visits ______

Did you get a referral from your Primary Care Physician if required by your ins. co.? Yes_____ No_____

Insurance Information / For Secondary Ins. Only
Policy Holder's ID/SS# / ______/ Policy Holder's ID/SS# / ______
Ins Co. Name / ______/ Ins. Co. Name / ______
Policy Holder's Name / ______/ Policy Holder's Name / ______
Relationship to client / ______/ Relationship to client / ______
Policy Holder's Address / ______/ Policy Holder's Address / ______
Policy/Group # / ______
______/ Policy/Group # / ______
______
Policy Holder's DOB / ______/ Policy Holder's DOB / ______
Male _____ Female _____ / Male _____Female _____
Employer / ______/ Employer / ______

How did you hear about our practice? ______

When you decided to call us, where did you get our phone number?______

May we thank your referral source? Yes _____ No____ If yes, referral address______

Did you search for more information about us on the internet? ______

Did you use a search engine? Yahoo _____, Google _____, AltaVista _____, Other ______

Did you visit our website? ______For what purpose? ______

Child/Adolescent Intake Form Page 1 Revised 09-10-07

Client Name______Date______

Have you received mental health care previously? Yes _____ No_____

If so, name of therapist or group? ______

When? ______

What issues were addressed? ______

In your own words, what issues bring you here at this time?

______

______

Describe academic functioning (learning problems): ______

______

Describe any major medical/physical problems: ______

List known allergies:

______

______

Primary Care Physician______Phone: ______

Address ______

Date of last visit ______

List current medications prescribed by this doctor:

Medication Daily Dose Condition Starting Date

______

Psychiatrist, if applicable ______Phone: ______

Address ______

Date of last visit ______

List current medications prescribed by this doctor:

Medication Daily Dose Condition Starting Date

______

Nearest relative or friend (not spouse) we may contact in case of emergency:

______

Name Relationship Phone

Child/Adolescent Intake Form Page 2 Revised 09-10-07