Behavioral Health New Patient Screening

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Behavioral Health New Patient Screening - Pediatric

If you are having a medical emergency, please call 911.

Patient Name *

Caregiver Name (if applicable)

Patient's Date of Birth *

YYYY

Best Phone Number for Contact *

Relationship to patient *

Self

Mother

Father

Grandparent

Foster Parent

If not the parent, do you have legal guardianship of the patient? *

Yes

1.) Urgent Symptoms: Has your child experienced any of the following symptoms in the last 14 days? (Check all that apply) *

Had thoughts or made statements about death or committing suicide

Engaged in self harm with an intent to die

Had thoughts or made statements about killing someone else

Heard voices that told them to do things like hurt themselves or others

None of the above symptoms

Any of these symptoms have occurred in the past 24 hours

Required

2.) Has the child been hospitalized in the last 90 days for mental health reasons? *

Yes

3.) What type of services are you seeking? *

Psychiatry (A doctor who can prescribe medication)

Individual Therapy (Talk therapy)

Required

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? *

Yes

5.a) Previous Diagnosis

5.b) Past/Current Medications

Preference for Appointment *

Monday

Tuesday

Wednesday

Thursday

Friday

Morning

Afternoon

Required

Notice

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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