Pediatric Behavioral Health Intake
Patient Information
Patient Name
Date of Birth
Age
Gender
Male
Female
Other
Parent/Guardian Information
Parent/Guardian Name
Phone Number
Email
Relationship to Patient
Reason for Visit
Primary Concerns/Behaviors
When did the concerns begin?
Medical & Developmental History
Significant Medical Conditions
Current Medications
Developmental Milestones
Allergies
School & Social History
School Name
Grade
Academic / Social Concerns
Family & Home Environment
Family Composition
Significant Family Stressors
Mental Health History
Previous Mental Health Diagnoses or Treatment
History of Hospitalizations
Current or Past Therapies