Test form conditional June 29 By laurin Pre-Screening Packet Step 1 of 4 25% INSURANCE INFORMATIONName of Insurance Company Name of Policy Holder DOB of Policy Holder MM slash DD slash YYYY Insurance Address Insurance Phone NumberMember ID# Group ID # Do you have secondary insurance? Yes Secondary Insurance Company Insurance Address Name of Policy Holder DOB of Policy Holder MM slash DD slash YYYY Insurance Phone NumberMember ID# Group ID # Please provide a copy of the front and back of your insurance card(s) Drop files here or Select files Max. file size: 128 MB. Name of Person Completing this form(Required) Legal Name of Child / Adolescent(Required) Nickname or name child routinely goes by Child's Date of Birth(Required) MM slash DD slash YYYY Age(Required) Home Address(Required)Other Address if applicable School Name System Grade Family DynamicsPrimary language spoken at home(Required) Secondary Language (if applicable) Marital Status(Required) Married Remarried Divorced Separated Widowed Single Cohabitants If married, how long have you been married If divorced, how long have the parents been divorced If divorced, who has physical custody? Is custody Full Joint Parent (1) / Guardian's Name First Last Home Phone NumberWork PhoneCell PhoneEmail Date of Birth MM slash DD slash YYYY Parent (1) / Guardian's Highest Level of Education Occupation Employer Parent (2) / Guardian's Name First Last Home Phone NumberWork PhoneCell PhoneEmail Date of Birth MM slash DD slash YYYY Highest Level of Education Occupation Employer Siblings:How many siblings does the child have?(Required)Please enter a number from 0 to 10.Sibling Name DOB MM slash DD slash YYYY Relationship Brother Sister Living in home? Yes No School Grade Sibling Name DOB MM slash DD slash YYYY Relationship Brother Sister Living in home? Yes No School Grade Sibling Name DOB MM slash DD slash YYYY Relationship Brother Sister Living in home? Yes No School Grade Sibling Name DOB MM slash DD slash YYYY Relationship Brother Sister Living in home? Yes No School Grade Please list info about other siblingsPlease indicate any special needs or concerns regarding the other children living in your home Psychological HistoryIs there a history of psychological issues in your family? (immedicate or extended)Autism Spectrum Disorder Yes No Who Learning Difficulties / Disabilities Yes No Who ADHD-ADD- Attention problems Yes No Who Depression / Bipolar Disorder Yes No Who Behavior problems at school Yes No Who Axiety Disorders (OCD, Phobias, etc) Yes No Who Intellectual Disabilities Yes No Who Psychosis / Dissociative Disorder Yes No Who Substance Abuse / Dependence Yes No Who Other Mental Health concerns (please explain)Has your child been evaluated in the past Yes No Company/Person Type When Copy Available Yes No Company/Person Type When Copy Available Yes No Company/Person Type When Copy Available Yes No Company/Person Type When Copy Available Yes No Please provide us with any other information you feel would be helpful to us understanding your childBehavioral Health Treatment History Has your child received behavioral health services in the past? Yes No if yes, please list the previous evaluationsDates Provider Therapeutic Intervention Responses Dates Provider Therapeutic Intervention Responses Dates Provider Therapeutic Intervention Responses Dates Provider Therapeutic Intervention Responses Prenatal and Perinatal HistoryDid the Birth mother receive regular prenatal care? Yes No Were there any complications during pregnancy? Yes No If yes please explain.Was the birth full-term? Yes No if not please explain.Were there concerns at birth? Yes No If yes please provide details including treatments.Education HistoryDoes your child’s teacher have concerns about him/her? Yes No If yes please explain. What is your child’s favorite subject/class? What is your child’s least preferred subject/class? Has your child ever repeated a grade? Yes No If yes, what grade(s)? GoalsPlease share 3 things you would like to your child to do more oftenPlease share 3 things you would like to your child to do oftenPlease let us know who to thank for referring you to us