General Patient Information
Please complete the following questions about yourself
Parent/Guardian Full Name
*
Prefix
First Name
Last Name
Preferred Name
Parent/Guardian Date of Birth
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicare Number
Medicare Number
IRN
Email
*
example@example.com
Relationship Status
Married
De Facto
Never Married
Seperated
Divorced
Widowed
Number of Children
Mobile Phone
*
Format: (000) 000-0000.
Home Phone
-
Phone Number
Preferred method of contact/confirmation
*
Mobile phone
Home phone
Email
How did you hear about us?
*
Please answer the following questions about your child
Child's Full Name
*
First Name
Last Name
Child Birth Date
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Medicare Number
Medicare Number
IRN
Medical History
If he/she is taking prescribed medication, please list them here:
How would you describe your child's physical health at present?
Very Good
Good
Fair
Unsatisfactory
Poor
Please describe your child's sleeping habits:
*
Normal
Sleeping too little
Sleeping too much
Disturbing dreams
Poor sleep quality
Describe your child's eating habits
*
Normal
Eating too little
Eating too much
Binge eating
Restricting
In the last year, has your child experienced any significant life changes or stressful situations?
Has your child ever experienced the following?
*
Rows
Yes
No
Extreme Depression
1
2
Wild Mood Swings
3
4
Rapid Speech
5
6
Extreme Anxiety
7
8
Panic Attacks
9
10
Difficulty Breathing
11
12
Drug Abuse
13
14
Phobias
15
16
Sleep Disturbances
17
18
Hallucinations
19
20
Unexplained Loss of Time
21
22
Unexplained Memory Loss
23
24
Frequent Body Complaints
25
26
Eating Disorder
27
28
Body Image Problems
29
30
Repetitive Thoughts (Obsessions)
31
32
Repetitive Behaviours (Hand-washing, Checking)
33
34
Homicidal Thoughts
35
36
Suicide Attempt
37
38
Has anyone in your family (Immediate or relatives) experienced difficulty with the following?
*
Rows
Yes
No
Depression
39
40
Bipolar Disorder
41
42
Personality Disorder
43
44
Anxiety Disorder
45
46
Panic Attacks
47
48
Schizophrenia
49
50
Alcohol/Substance Abuse
51
52
Eating Disorder
53
54
Learning Disabilities
55
56
Trauma History
57
58
Suicide Attempt
59
60
Is there anything else you think we should know?
Assignment and Release
Signature of Parent or Guardian
*
Date
*
-
Year
-
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Name
First Name
Last Name
Submit Form
Should be Empty: