Request Services – Social Perspectives

Step 1 of 4

25%

INSURANCE INFORMATION

Name of Insurance Company

Name of Policy Holder

DOB of Policy Holder

MM slash DD slash YYYY

Insurance Address

Insurance Phone Number

Member 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 Number

Member ID#

Group ID #

Please provide a copy of the front and back of your insurance card(s)

Drop files here or

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

District

Grade

If you have any problems with this form, please contact us. You can also use "Save & Continue" button below to save your work.

Family Dynamics

Primary 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/separated, how long have the parents been divorced/separated

If divorced, who has physical custody?

Is custody

Full

Joint

Parent (1) / Guardian's Name

First Last

Home Phone Number

Work Phone

Cell Phone

Preferred Contact

work phone

cell phone

text on cell

Parent (2) work phone

Parent (2) cell phone

Parent (2) text on cell

Parent (2) email

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 Number

Work Phone

Cell Phone

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

School

Grade

Sibling Name

DOB

MM slash DD slash YYYY

Relationship

Brother

Sister

Living in home?

Yes

School

Grade

Sibling Name

DOB

MM slash DD slash YYYY

Relationship

Brother

Sister

Living in home?

Yes

School

Grade

Sibling Name

DOB

MM slash DD slash YYYY

Relationship

Brother

Sister

Living in home?

Yes

School

Grade

Please list info about other siblings

Please indicate any special needs or concerns regarding the other children living in your home

Psychological History

Is there a history of psychological issues in your family? (immediate or extended)

Issues are with

Child

Other Family Member

Autism Spectrum Disorder

Yes

Who(Required)

Learning Difficulties / Disabilities

Yes

Who(Required)

ADHD-ADD- Attention problems

Yes

Who(Required)

Depression / Bipolar Disorder

Yes

Who(Required)

Behavior problems at school

Yes

Who(Required)

Axiety Disorders (OCD, Phobias, etc)

Yes

Who(Required)

Intellectual Disabilities

Yes

Who(Required)

Psychosis / Dissociative Disorder

Yes

Who(Required)

Substance Abuse / Dependence

Yes

Who(Required)

Other Mental Health concerns (please explain)

Has your child been evaluated in the past

Yes

Company/Person

Type

When

Copy Available

Yes

Company/Person

Type

When

Copy Available

Yes

Company/Person

Type

When

Copy Available

Yes

Company/Person

Type

When

Copy Available

Yes

Please provide us with any other information you feel would be helpful to us understanding your child

Behavioral Health Treatment History

Has your child received behavioral health services in the past?

Yes

if yes, please list the previous evaluations

Dates

Provider

Therapeutic Intervention

Responses

Dates

Provider

Therapeutic Intervention

Responses

Dates

Provider

Therapeutic Intervention

Responses

Dates

Provider

Therapeutic Intervention

Responses

Prenatal and Perinatal History

Did the Birth mother receive regular prenatal care?

Yes

Were there any complications during pregnancy?

Yes

If yes please explain.

Was the birth full-term?

Yes

if not please explain.

Were there concerns at birth?

Yes

If yes please provide details including treatments.

Education History

Does your child’s teacher have concerns about him/her?

Yes

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

If yes, what grade(s)?

Goals

Please share 3 things you would like to your child to do more often

Please share 3 things you would like to your child to do less often

Please let us know who to thank for referring you to us

Other

Are there any religious, legal, cultural, spiritual or other accommodations/concerns we should be aware of ?

CAPTCHA