Behavioral Health New Patient Screening - Pediatric
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Patient Name *
Caregiver Name (if applicable)
Patient's Date of Birth *
Best Phone Number for Contact *
Relationship to patient *
If not the parent, do you have legal guardianship of the patient? *
1.) Urgent Symptoms: Has your child experienced any of the following symptoms in the last 14 days? (Check all that apply) *
2.) Has the child been hospitalized in the last 90 days for mental health reasons? *
3.) What type of services are you seeking?   *
4.) Why are you currently seeking mental health services for your child at this time? *
5.) Is your child currently under the care of a psychiatrist or therapist? *
5.a) Previous Diagnosis
5.b) Past/Current Medications
Preference for Appointment *
Please bring all documents showing guardianship or authority to consent to medical services for the child.  
During your child’s visit, the Legacy provider will create a treatment plan which may or may not include medications your child has taken before. Bringing documents from previous treatment (including ADHD testing results) will help your child’s provider in determining if additional information or testing will be necessary before a prescription is provided.
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